Sun protection and skin self-examination in melanoma survivors

A Digital Intervention to Improve Skin Self-Examination Among Survivors of Melanoma: Protocol for a Type-1 Hybrid Effectiveness-Implementation Randomized Trial

BACKGROUND

Although melanoma survival rates have improved in recent years, survivors remain at risk of recurrence, second primary cancers, and keratinocyte carcinomas. The National Comprehensive Cancer Network recommends skin examinations by a physician every 3 to 12 months. Regular thorough skin self-examinations (SSEs) are recommended for survivors of melanoma to promote the detection of earlier-stage, thinner melanomas, which are associated with improved survival and lower treatment costs. Despite their importance, less than a quarter of survivors of melanoma engage in SSEs.

OBJECTIVE

Previously, our team developed and evaluated a web-based, fully automated intervention called mySmartSkin (MSS) that successfully improved SSE among survivors of melanoma. Enhancements were proposed to improve engagement with and outcomes of MSS. The purpose of this paper is to describe the rationale and methodology for a type-1 hybrid effectiveness-implementation randomized trial evaluating the enhanced MSS versus control and exploring implementation outcomes and contextual factors.

METHODS

This study will recruit from state cancer registries and social media 300 individuals diagnosed with cutaneous malignant melanoma between 3 months and 5 years after surgery who are currently cancer free. Participants will be randomly assigned to either enhanced MSS or a noninteractive educational web page. Surveys will be collected from both arms at baseline and at 3, 6, 12, and 18 months to assess measures of intervention engagement, barriers, self-efficacy, habit, and SSE. The primary outcome is thorough SSE. The secondary outcomes are the diagnosis of new or recurrent melanomas and sun protection practices.

RESULTS

Multilevel modeling will be used to examine whether there are significant differences in survivor outcomes between MSS and the noninteractive web page over time. Mixed methods will evaluate reach, adoption, implementation (including costs), and potential for maintenance of MSS, as well as contextual factors relevant to those outcomes and future scale-up.

CONCLUSIONS

This trial has the potential to improve outcomes in survivors of melanoma. If MSS is effective, the results could guide its implementation in oncology care and nonprofit organizations focused on skin cancers.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/52689.

Skin cancer survivorship and sun protection behaviors in the United States

BACKGROUND

Skin cancer survivors are more vulnerable to subsequent skin cancers and other malignancies, but previous studies have not examined in detail their sun protection behavior prevalence by sociodemographic factors. We aimed to understand the sociodemographic disparities in the prevalence of three important types of sun protection behaviors: using sunscreen, seeking shade, and wearing protective clothing, among skin cancer survivors and those without skin cancer history.

METHODS

We used the 2015 U.S. National Health Interview Survey to analyze 29,523 participants, of which 772 were skin cancer survivors and 28,751 were those without skin cancer history. We assessed overall and specific sun protection behavior prevalence based on using sunscreen, seeking shade, and wearing protective clothing. Weighted Poisson regression was used to estimate prevalence ratios.

RESULTS

Melanoma and nonmelanoma skin cancer survivors had similar overall sun protection behavior (p > .05). Among all skin cancer survivors, 36.0% infrequently used sunscreen, 50.2% infrequently wore protective clothing, 47.8% infrequently sought shade, and 30.0% lacked frequent overall sun protection, which significantly differed from those without skin cancer history (p < .0001). The prevalence of frequent overall sun protection behavior was lower for those who were younger at survey, males, less educated, single or never married, or lived in poverty, regardless of their skin cancer history (p < .01).

CONCLUSIONS

By identifying subpopulations with higher prevalence of infrequent sun protection among those with or without skin cancer history, our findings may encourage efforts to reduce sociodemographic disparities in sun protection behaviors and promote primary and tertiary skin cancer prevention.

Evaluating SunSmart: a brief educational intervention promoting sun protection in young adult cancer survivors

PURPOSE

Young adult cancer survivors (YACS) are at risk for secondary skin cancers but relevant interventions have not been validated in this population. To address this, we designed and tested SunSmart, a set of two educational videos designed to promote sun protection (SP). One provides SP education (Information) and the second combines SP education with content on negative appearance consequences of sun exposure (Information + Appearance).

METHODS

One hundred ninety-three YACS (aged 18-35) were randomized to one of three groups: (1) Information, (2) Information + Appearance, or (3) control (sleep hygiene video). Participants completed measures on SP behaviors at baseline and follow-up. One-way ANCOVAs examined the intervention effect on follow-up SP behaviors controlling for baseline behaviors.

RESULTS

The intervention did not significantly affect SP behaviors. However, secondary analyses limited to participants with the lowest baseline SP adherence found that the Information + Appearance group had significantly lower intentional sun exposure than the control group (p = 0.02) at follow-up.

CONCLUSIONS

Contrary to hypotheses, the SunSmart intervention did not significantly improve sun protection in YACS, even when it presented information on negative appearance consequences of sun exposure. However, secondary analyses suggest SunSmart may be more effective in YACS with the lowest SP adherence. Future research is required to improve intervention efficacy with YACS (e.g., increased focus on secondary cancer risks).

IMPLICATIONS FOR CANCER SURVIVORS

Despite their increased risk of secondary skin cancer, YACS in the current study reported significant sun exposure and inadequate SP. The need for development and validation of effective interventions to address these concerns remains.

User Experiences in a Digital Intervention to Support Total Skin Self-examination by Melanoma Survivors: Nested Qualitative Evaluation Embedded in a Randomized Controlled Trial

BACKGROUND

Melanoma is a relatively common cancer type with a high survival rate, but survivors risk recurrences or second primaries. Consequently, patients receive regular hospital follow-up, but this can be burdensome to attend and not optimally timed to detect arising problems. Total skin self-examination (TSSE) supports improved clinical outcomes from melanoma via earlier detection of recurrences and second primaries, and digital technology has the potential to support TSSE. Recent research with app-based interventions aimed at improving the well-being of older adults has found that they can use the technology and benefit from it, supporting the use of digital health care in diverse demographic groups. Thus, the Achieving Self-directed Integrated Cancer Aftercare (ASICA) digital health care intervention was developed. The intervention provided melanoma survivors with a monthly prompt to perform a TSSE as well as access to a dermatology nurse who provided them with feedback on photographs and descriptions of their skin.

OBJECTIVE

We aimed to explore participants' attitudes, beliefs, and experiences regarding TSSE practices. Furthermore, we explored how participants experienced technology and how it influenced their practice of TSSE. Finally, we explored the practical and technical experiences of ASICA users.

METHODS

This was a nested qualitative evaluation within a dual-center randomized controlled trial of the ASICA intervention. We conducted semistructured telephone interviews with the participants during a randomized controlled trial. The participants were purposively sampled to achieve a representative sample with representative proportions by age, sex, and residential geography. Interviews were transcribed verbatim and analyzed using a framework analysis approach applied within NVivo 12.

RESULTS

A total of 22 interviews were conducted with participants from both groups. In total, 40% (9/22) of the interviewed participants were from rural areas, and 60% (13/22) were from urban areas; 60% (13/22) were from the intervention group, and 40% (9/22) were from the control group. Themes evolved around skin-checking behavior, other people's input into skin checking, contribution of health care professionals outside ASICA and its value, ideas around technology, practical experiences, and potential improvements. ASICA appeared to change participants' perceptions of skin checking. Users were more likely to report routinely performing TSSE thoroughly. There was some variation in beliefs about skin checking and using technology for health care. Overall, ASICA was experienced positively by participants. Several practical suggestions were made for the improvement of ASICA.

CONCLUSIONS

The ASICA intervention appeared to have positively influenced the attitudes and TSSE practices of melanoma survivors. This study provides important qualitative information about how a digital health care intervention is an effective means of prompting, recording, and responding to structured TSSE by melanoma survivors. Technical improvements are required, but the app offers promise for technologically enhanced melanoma follow-up in future.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03328247; https://clinicaltrials.gov/ct2/show/NCT03328247?term=ASICA&rank=1.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-019-3453-x.

Dermatology Patients' Knowledge of Sunscreen Guidelines at a University Hospital in Saudi Arabia

Objective

The goal of this study is to assess the knowledge and attitude of dermatology patients regarding sunscreen use as recommended by the American Academy of Dermatology.

Methods

This was an observational cross-sectional study at a university hospital in Riyadh. Participants were asked to complete a questionnaire to measure their knowledge and attitude regarding sunscreen use. Results were analyzed using a chi-square test.

Results

Most participants heard about sunscreen (93.4%) and had indicated previous sunscreen use (72%). Sunscreen use was higher among women and participants with a postgraduate education. Sunscreen knowledge was higher among women, participants with non-photosensitive disorders, and participants with Fitzpatrick I, II, and III skin types. A total of 80% knew the worst time for sun exposure, but only 20.5% of the participants knew that sunscreen should be applied daily throughout the year, and 13.5% knew the correct minimum recommended SPF. A total of 34% were aware of the minimum time allowed for sunscreen application before sun exposure, and 20% were aware of the longest period allowed between reapplications. Only 4.5% knew the proper amount of sunscreen to cover the entire body.

Conclusion

Our study revealed that most participants had heard of sunscreen, however their knowledge of the guidelines for sunscreen use was poor. Only 33% of the participants had received a recommendation for using sunscreen from their general practitioner or dermatologist. More comprehensive and directed efforts need to be made in counselling and educating these patients on proper sunscreen practice.

mySmartCheck, a Digital Intervention to Promote Skin Self-examination Among Individuals Diagnosed With or at Risk for Melanoma: A Randomized Clinical Trial

BACKGROUND

Regular skin self-examination (SSE) reduces melanoma mortality but is not often conducted.

PURPOSE

To promote SSE performance in individuals at increased risk for melanoma.

METHODS

One hundred sixteen individuals at heightened risk for development of melanoma (i.e., personal/family history of melanoma, high-risk mole phenotype) who did not conduct a thorough SSE during in the prior 3 months were randomly assigned to receive either an automated internet-based intervention (mySmartCheck) or usual care (UC). One hundred sixteen participants completed surveys before random assignment and 99 completed the follow-up survey 13-weeks afterward. The primary outcome was participant self-reported examination (SSE) of all 15 parts of the body in the last 3 months. Secondary outcomes were SSE of any part of the body in the last 3 months and number of body parts examined during the last SSE.

RESULTS

More mySmartCheck participants examined all 15 body parts (32.6% vs. 7.1%, p = .001). More individuals in mySmartCheck reported conducting SSE on any body part than those in UC (81.4% vs. 62.5%, p = .04). Effect sizes were large (d = 1.19 all 15 body parts) to moderate (d = 0.55 for any body part). mySmartCheck participants examined more body areas than UC participants (12.7 vs. 10.3, p = 0.003) during the last SSE. Participants in mySmartCheck reported higher levels of knowledge of suspicious lesions, SSE benefits, SSE self-efficacy, and planning for SSE, and lower SSE barriers, than those assigned to UC.

CONCLUSIONS

mySmartCheck had a significant positive impact on SSE performance and behaviors. Additional research with a larger sample size, a longer follow-up, and more varied clinical settings is needed.

TRIAL REGISTRATION

ClinicalTrials.gov registration # NCT03725449 (https://clinicaltrials.gov/ct2/show/NCT03725449).

Theory-Based Problem Formulation and Ideation in mHealth

This article reports on an investigation into how to improve problem formulation and ideation in Design Science Research (DSR) within the mHealth domain. A Systematic Literature Review of problem formulation in published mHealth DSR papers found that problem formulation is often only weakly performed, with shortcomings in stakeholder analysis, patient-centricity, clinical input, use of kernel theory, and problem analysis. The study proposes using Coloured Cognitive Mapping for DSR (CCM4DSR) as a tool to improve problem formulation in mHealth DSR. A case study using CCM4DSR found that using CCM4DSR provided a more comprehensive problem formulation and analysis, highlighting aspects that, until CCM4DSR was used, weren’t apparent to the research team and which served as a better basis for mHealth feature ideation.

Cancer Risk Perceptions Among People Who Check Their Skin for Skin Cancer: Results from the 2017 U.S. Health Information National Trends Survey (HINTS)

When detected early, melanoma is highly treatable and rarely fatal. Self-skin checks can identify changes in moles that could be an indicator of melanoma. Cancer risk perceptions may influence the uptake of important preventive health behaviors such as self-skin checks. The purpose of this study is to examine cancer risk perception factors associated with those who have checked their skin for signs of skin cancer using the 2017 HINTS data. Retrospective cross-sectional analysis of a nationally representative sample of U.S. adults using the Health Information National Trends Survey (HINTS). Logistic regressions were performed to identify associations between having checked skin for signs of skin cancer, risk perceptions, and demographic variables. White women over the age of 45 with a college degree and annual incomes greater than $75,000 were more likely to check their skin for signs of skin cancer. More than a third reported they would rather not know if they had cancer and more than 60% had some level of worry about having cancer. Those with a personal or family history of cancer were more likely to check. HINTS is a cross-sectional survey which provides only a glimpse of behavioral predictors. Self-skin checks are simple and cost-effective to detect melanoma early and improve outcomes. Fear and worry about cancer were significant factors in the likelihood of checking skin for signs of skin cancer. Population-based strategies could be developed to reduce concerns about early detection.

Follow-up of primary melanoma patients with high risk of recurrence: recommendations based on evidence and consensus

In spite of the good prognosis of patients with early-stage melanoma, there is a substantial proportion of them that develop local or distant relapses. With the introduction of targeted and immune therapies for advanced melanoma, including at the adjuvant setting, early detection of recurrent melanoma and/or second primary lesions is crucial to improve clinical outcomes. However, there is a lack of universal guidelines regarding both frequency of surveillance visits and diagnostic imaging and/or laboratory evaluations. In this article, a multidisciplinary expert panel recommends, after careful review of relevant data in the field, a consensus- and experience-based follow-up strategy for melanoma patients, taking into account prognostic factors and biomarkers and the high-risk periods and patterns of recurrence in each (sub) stage of the disease. Apart from the surveillance intensity, healthcare professionals should focus on patients' education to perform regular self-examinations of the skin and palpation of lymph nodes.

Moderators of the Effects of mySmartSkin, a Web-Based Intervention to Promote Skin Self-examination and Sun Protection Among Individuals Diagnosed With Melanoma

BACKGROUND

Identifying the characteristics of persons who benefit more from behavioral interventions can help health care providers decide which individuals should be offered particular interventions because this is the subgroup of persons who are more likely to derive greater benefit from the intervention and refine the underlying constructs of the model guiding the intervention.

PURPOSE

This study evaluated possible demographic, medical, knowledge and attitudinal, and psychosocial variables that may moderate the impact of an online intervention, called mySmartSkin (MSS), on engagement in skin self-examination (SSE) and sun protection behaviors among melanoma survivors.

METHODS

Participants completed a baseline survey and were then randomized to the MSS condition or usual care. Follow-up surveys were completed by participants at 8-, 24-, and 48-week postrandomization.

RESULTS

A greater impact of MSS on SSE was illustrated among participants with more phenotypic skin cancer risk factors and participants reporting lower baseline self-efficacy in conducting SSE. A more favorable response of MSS on sun protection behaviors was shown when initial knowledge about abnormal lesions and sun protection barriers were high. Greater use of MSS and more favorable evaluations of it were also associated with higher intervention response.

CONCLUSIONS

Future studies seeking to improve SSE and sun protection among melanoma survivors might benefit from focusing on survivors who report more skin cancer risk factors, lower self-efficacy in conducting SSE, less knowledge about what abnormal skin lesions look like, more perceived barriers to sun protection behaviors, and less worry about recurrence and cancer-related distress.

Achieving integrated self-directed Cancer aftercare (ASICA) for melanoma: how a digital intervention to support total skin self-examination was used by people treated for cutaneous melanoma

BACKGROUND

Melanoma incidence has quadrupled since 1970 and melanoma is now the second most common cancer in individuals under 50. Targeted immunotherapies for melanoma now potentially enable long-term remission even in advanced melanoma, but these melanoma survivors require ongoing surveillance, with implications for NHS resources and significant social and psychological consequences for patients. Total skin self-examination (TSSE) can detect recurrence earlier and improve clinical outcomes but is underperformed in the UK. To support survivors, the Achieving Self-directed Integrated Cancer Aftercare (ASICA) intervention was developed to prompt and improve TSSE performance, with subsequent reporting of concerns and submission of skin photos to a Dermatology Nurse Practitioner (DNP). ASICA was delivered as a randomized pilot trial.

METHODS

This paper reports on process evaluation. Data on participants' demographics and the concerns they reported during the trial were tabulated and displayed using Microsoft Excel and SPSS. We explored which participants used ASICA, and how frequently, to report any skin concerns. We also determined how the interactions had worked in terms of quality of skin photographs submitted, clinical assessments made by the DNP, and the assessments and decisions made for each concern. Finally, we explored significant events occurring during the trial. Data on participants' demographics and the concerns they reported during the trial were tabulated and displayed using SPSS. A semi-structured interview was undertaken with the DNP to gain perspective on the range of concerns presented and how they were resolved.

RESULTS

Of 121 recruited melanoma patients receiving ASICA for 12 months, 69 participants submitted a total of 123 reports detailing 189 separate skin-related concerns and including 188 skin photographs. Where participants fully complied with follow-up by the DNP, concerns were usually resolved remotely, but 19 (10.1%) were seen at a secondary care clinic and 14 (7.4%) referred to their GP. 49 (25.9%) of concerns were not completely resolved due to partial non-compliance with DNP follow-up.

CONCLUSION

Melanoma patients randomized to the ASICA intervention were able to report skin-related concerns that could be resolved remotely through interaction with a DNP. Feasibility issues highlighted by ASICA will support further development and optimization of this digital tool.

TRIAL REGISTRATION

Clinical Trials.gov , NCT03328247 . Registered on 1 November 2017.

Family Attitudes and Communication about Sun Protection and Sun Protection Practices among Young Adult Melanoma Survivors and Their Family Members

Young melanoma survivors and their family are at increased risk for developing melanoma, but seldom engage in sun protection behaviors. Little is known about the role of family factors in sun protection. Our goals were: 1) examine correspondence between survivors and family sun protection, individual attitudes, and family attitudes and communication about risk-reducing behaviors, and; 2) evaluate the mediating role of family attitudes and communication in the association between individual sun protection attitudes and behavior. Measures of individual attitudes, family attitudes and communication, and sun protection behaviors were completed by 529 participants. Multilevel modeling assessed family correspondence in sun-related attitudes and behaviors and mediation. Families had varying levels of shared attitudes and behaviors, with higher correspondence for family norms. Survivors reported stronger family norms, greater family benefits, and more discussion than siblings. For both sexes, family discussion was associated with higher sun protection. For women only, more favorable attitudes were associated with sun protection partly because women discussed sun protection with family and held stronger norms. Because families' attitudes and practices correspond, family-focused interventions may prove effective. Among females, increasing risk awareness and sunscreen efficacy and overcoming barriers may foster enhanced normative standards, communication about, and engagement in sun protection.

Sun exposure reduction by melanoma survivors with wearable sensor providing real-time UV exposure and daily text messages with structured goal setting

Despite knowledge of subsequent melanoma risk and the benefit of sun protection in risk reduction, melanoma survivors often do not engage in adequate sun protection and continue to sunburn at rates similar to individuals without a history of skin cancer. This novel intensive intervention provided a wearable UV sensor delivering real-time UV exposure with a smartphone and daily text messages. On days 1-10 (period 1), behavioral facilitation and outcome expectancies messages were provided. On day 10, participants reviewed and reflected on their daily UV exposure on the previous 10 days and set goals for improving sun protection. Then on days 11-21 (period 2) self-efficacy and self-regulation messages were provided. Sixty melanoma survivors were randomized (1:1) to receive structured or unstructured goal setting queries on day 10. Controlling for cloudy/rain conditions with less UV due to weather, there was a time effect with a significant decrease in UV exposure from periods 1-2 [period 1-2, F (59) = 22.60, p < 0.0001]. In this short-term study, melanoma survivors managed their daily UV exposure to stay below their maximum tolerated UV dose. ClinicalTrials.gov Protocol Record NCT0334796, date of registration Nov 15, 2017.

The impact of physician support on skin self-examination among melanoma patients: A serial mediation model with self-efficacy and intentions to perform skin exams

OBJECTIVE

Melanoma is the most lethal of skin cancers; however, survival rates are excellent if the tumor is detected early. Clinical practice guidelines for melanoma follow-up care recommend regular skin self-examination (SSE) for individuals at high risk for melanoma. The current analyses tested whether self-efficacy for SSE and intention to perform SSE mediate the relationship between physician support for SSE and SSE behavior among a sample of melanoma patients.

METHODS

We ran a serial mediation model on a cross-sectional sample of melanoma patients (n = 154) drawn from an observational study with longitudinal follow-up.

RESULTS

Self-efficacy and intention to perform SSE sequentially mediated the relationship between physician support and SSE behaviors (β = .31, t(152) = 3.61, p < .001 without mediators versus β = .11, t(150) = 1.50, p = .14 with mediators), as supported by a significant total indirect effect (β = .21, [95 % CI = .08-.35]).

CONCLUSION

Self-efficacy for SSE and intention to perform SSE together explain the link between perceived physician support for SSE and the practice of SSE.

PRACTICE IMPLICATIONS

Physician communication about the importance of SSE plays an important role in encouraging patient adherence to SSE recommendations and, thus, supporting early detection efforts.

Randomized controlled trial of the mySmartSkin web-based intervention to promote skin self-examination and sun protection among individuals diagnosed with melanoma

Adherence to regular, thorough skin self-examination (SSE) and consistent sun protection behaviors among melanoma survivors is relatively low. This study reports on the impact of an online intervention, called mySmartSkin (MSS), on engagement in SSE and sun protection behaviors among melanoma survivors, as well as the mediators of the intervention effects. The intervention was compared with usual care (UC), and primary outcomes were assessed at 24 and 48 weeks. Short-term outcomes were also evaluated at 8 weeks postbaseline. Results demonstrate a significant effect on SSE and sun protection. At all three follow-up assessments, the proportion of participants reporting conducting a thorough SSE in the time since the previous assessment was significantly greater in MSS than in UC. In addition, both multivariate and univariate analyses indicated that engagement in sun protection behaviors was significantly higher in MSS than UC at 24 weeks, but the effect on sun protection at 48 weeks was significant only in multivariate analyses. Beneficial effects of MSS were significantly mediated by knowledge about melanoma and characteristics of suspicious lesions, as well as self-efficacy. Participant engagement in MSS was satisfactory, with approximately two-thirds of participants completing at least two of the three core components. Content was rated as highly trusted, easy to understand, easy to navigate, and helpful. In conclusion, MSS illustrated significant and durable effects on SSE and mixed results on sun protection. Future studies should consider ways to further enhance treatment effects and engagement in MSS.

Review of educational tools for skin self-examination: A qualitative analysis of laypeople's preferences

ISSUE ADDRESSED

Skin self-examination (SSE) empowers individuals to be aware of their skin and to identify and present to a doctor with any suspicious lesions; however evidence-based, clear guidance for SSE is lacking.

METHODS

A new acronym entitled SCAN (Sore, Changing, Abnormal, New) was compiled to help laypeople recognise early signs of skin cancer. This study undertook a qualitative investigation on how well laypeople understand SCAN and other commonly used educational tools (ABCDE, AC, and "ugly duckling"), whether they have a preferred SSE tool, and whether pictorial presentations enhance their understanding.

RESULTS

Seven focus groups were conducted with 28 participants (age range 19-78 years), including 6 participants with a previous melanoma diagnosis. Among all the educational tools presented, SCAN was commonly described as the favoured to guide SSE. SCAN was perceived as patient-oriented due to its simplicity and use of easily understood words, while other tools, although perceived as positive in some aspects, were often identified as complex, difficult to understand and aimed towards clinician use. Pictorial presentations were desired as part of an educational tool; however, many also raised their potential disadvantages.

CONCLUSION

This was the first study to determine the patient perspective of SCAN and established a diverse range of potential quality indicators for SSE educational tools. SO WHAT?: The findings of this study suggest that current widely used SSE tools may not be the most effective to promote SSE. SCAN may be preferred, as it simplifies SSE by using lay language and is applicable to all skin cancers.

Correlates of sun protection behaviors among melanoma survivors

BACKGROUND

The study objective was to assess potential correlates of sun protection behaviors among melanoma survivors.

METHODS

Participants were 441 melanoma survivors recruited from three health centers and a state cancer registry in the United States. Sun protection behaviors (sunscreen, shade, protective shirts, and hats) were assessed through an online survey, as were potential correlates (demographic, melanoma risk, knowledge and beliefs, psychological and social influence factors). Hierarchical multiple regression analyses were conducted.

RESULTS

Correlates of sun protection behaviors included education, skin cancer risk factors, melanoma knowledge and beliefs, melanoma worry and distress, physician recommendation for sun protection, injunctive norms, and pro-protection beliefs (e.g., perceived barriers, self-efficacy).

CONCLUSIONS

Future efforts to improve sun safety among melanoma survivors may benefit from targeting individuals with lower education levels, and addressing sun protection social influence, barriers, and self-efficacy.

Prevalence and correlates of skin self-examination behaviors among melanoma survivors: a systematic review

Melanoma is the most common cause of skin cancer deaths, and individuals who have had melanoma have an increased risk of developing new melanomas. Doing regular self-examinations of skin enables one to detect thinner melanomas earlier when the disease is more treatable. The aim of this systematic review is to characterize and evaluate the existing literature on the prevalence and correlates of skin self-examination (SSE) behaviors among adult melanoma survivors in the USA and Canada. A computerized literature search was performed using PubMed, Google Scholar, and ScienceDirect. The inclusion criteria for the studies were: (a) reported results for adult melanoma survivors in the USA or Canada, (b) papers described empirical research, (c) assessed SSE and related behaviors, and (d) papers were published in a peer-reviewed journal in the past 20 years. Key phrases such as "skin self-examination/SSE in melanoma survivors in the United States" and "correlates of skin self-examination/SSE" were used. Based on the inclusion criteria, 30 studies were included in the systematic review. SSE prevalence varied depending on how SSE was defined. Demographics and factors (gender, education level, patient characteristics, partner assistance, and physician support) associated with SSE were identified. Findings of this review show evidence for the need to have a consistent way to assess SSE and suggest different types of correlates on which to focus in order to promote SSE and reduce the risk of melanoma recurrence in survivors. This systematic review and its protocol have been registered in the international database of prospectively registered systematic reviews in health and social care (PROSPERO; ID: 148878).

Sunscreen application technique amongst patients with a history of skin cancer

BACKGROUND

Data on how patients with a history of skin cancer apply sunscreen are lacking.

OBJECTIVE

To characterize (1) gender differences in sunscreen application technique (quantity used, anatomic site coverage, and time allocated) and (2) differences in sunscreen application to unaffected skin versus previous skin cancer sites.

METHODS

Subjects with a history of skin cancer were asked to apply sunscreen to their head as they normally would. The amount of sunscreen used and application time were recorded. Before and after photos were taken. Using Wood's lamp lighting, an anatomic site coverage score was rated on an ordinal scale (1 = 0-25%, 2 = 26-50%, 3 = 51-75%, 4 = 76-100% coverage).

RESULTS

Males used 530 mg more sunscreen (p < 0.001) and applied approximately 5 mg/cm² of sunscreen versus women, who applied 2 mg/cm². The average coverage score was 3.27. Males were 7.61 times more likely to adequately apply sunscreen to the ears (p = 0.001). No differences were noted in application times. Coverage scores were similar for unaffected skin and previous skin cancer sites.

LIMITATIONS

Observations in a controlled setting may not reflect usual sunscreen application practices.

CONCLUSIONS

Overall, skin cancer survivors of both genders effectively applied sunscreen in line with recommended quantity guidelines, but men were significantly better at protecting their ears.

Prevalence and correlates of skin self-examination practices among cutaneous malignant melanoma survivors

Melanoma patients are at elevated risk for recurrence of the primary cancer as well as second primary melanomas. Regular skin self-examination (SSE) is recommended as part of follow-up surveillance. In this study, we examined SSE performance and comprehensiveness as well as knowledge and attitudinal correlates of SSE performance and comprehensiveness. Four hundred forty-one melanoma survivors completed measures of SSE performance as well as knowledge and attitudes about SSE and melanoma. Approximately two-thirds of the sample reported having conducted an SSE in the past two months; the average number of body parts examined was 10.64 (out of 15 maximum). Only 7.5% of the sample checked all 15 body parts. Greater worry about recurrence, fewer barriers to SSE, more planning for when to conduct SSE, and more confidence in the ability to conduct SSE and recognize a suspicious growth were associated with both SSE performance and greater SSE comprehensiveness. Physician influence was positively associated with SSE performance. Survivor education efforts may benefit from reminding survivors to check hard-to-see and sensitive areas, develop a plan for how to ask for assistance in conducting exams, as well as use mirrors to see hard-to-reach areas. Addressing perceived SSE barriers, fostering SSE planning, and improving SSE self-efficacy may be important foci for intervention efforts to enhance SSE performance and comprehensiveness.

Short and long-term barriers and facilitators of skin self-examination among individuals diagnosed with melanoma

Background

Melanoma can be lethal if not detected early and treated. Early detection can be facilitated via skin self-examination (SSE) and as such, SSE is part of melanoma follow-up care for individuals with a prior history, who face a life-long risk of reoccurrence. The objective of the current study was to identify short- and long-term predictors of SSE among melanoma survivors to inform future prevention interventions in high-risk groups.

Method

This is an observational study with longitudinal assessments conducted with adult melanoma patients in active follow-up care.

Primary outcome measures

Behavioral outcomes, comprehensive SSE (checking up to 5 body areas in the last 3 months) and optimal SSE (checking the entire body at least monthly in the last 3 months) were assessed at 3, 12, and 24 months post a dermatological educational session on skin cancer prevention. T tests and chi square analyses were used to examine changes in outcomes from 3 to 12 and 24 months. Linear and logistic regression models were used to examine the association between predictors and the primary outcomes.

Results

Comprehensive SSE did not decrease significantly from 3 (M = 2.7, SD = 1.1) to 12 (M = 2.6, SD = 1.2) and 24 months (M = 2.4, SD = 1.2) post the education session, with the stronger predictor at all timepoints being intentions to perform SSE. Optimal SSE was higher at 3 months (59%) compared to 12 (46%) and 24 months (34%), with key predictors including self-efficacy and intentions to perform SSE and male sex at 3 months post; self-efficacy and reliance on medical advice at 12 months; and (lower) education and self-efficacy at 24 months.

Conclusions

The key findings of this study are that 1) survivors maintain SSE behaviour over time, but rates of SSE performed in agreement with medical recommendations are higher immediately post standard dermatological education (i.e. usual care) and decrease somewhat over a 24-month period; and 2) the strongest psycho-social predictors of SSE are intentions and self-efficacy to perform the behavior, which are highly modifiable, for example via motivational interviewing and goal setting health interventions.

Randomized controlled trial of the mySmartSkin web-based intervention to promote skin self-examination and sun protection behaviors among individuals diagnosed with melanoma: study design and baseline characteristics

>1.2 million people in the United States have a personal history of melanoma skin cancer and are at increased risk for disease recurrence and second primary melanomas. Many of these individuals do not follow recommendations to conduct regular, thorough skin self-examinations that facilitate early disease detection and do not sufficiently engage in sun protection behaviors. In this project, we are conducting a randomized controlled trial of an innovative, tailored, theory-driven Internet intervention-called mySmartSkin-to promote these behaviors among melanoma patients. This paper outlines the study design and characteristics of the study sample. A total of 441 patients were recruited (40.9% response rate) and randomized to the mySmartSkin or a Usual Care condition. Participants complete surveys at baseline and 8 weeks, 24 weeks, and 48 weeks later. The primary aim of the project is to examine the impact of mySmartSkin versus Usual Care on skin self-examination and sun protection behaviors. The secondary aim focuses on identifying mediators of the intervention's effects. In an exploratory aim, we will examine potential moderators of the impact of the intervention. At baseline, the recruited participants had a mean age of 61 years, 49% were female, 7.5% met criteria for having conducted a recent, thorough skin self-examination, and the mean score on the index of sun protection behaviors was 3.3 (on a scale from 1 to 5). The results of the project will determine whether the mySmartSkin intervention is efficacious in promoting skin self-examination and sun protection behaviors among individuals diagnosed with melanoma. Trial registration: ClinicalTrials.govNCT03028948.

Skin Self-Examination: Partner Comfort and Support During Examinations as Predictors of Self-Efficacy in Patients At Risk for Melanoma Recurrence

BACKGROUND

Skin self-examination (SSE) is an effective method for melanoma survivors to detect potential cancerous growths sooner.

OBJECTIVES

The purpose of this study was to examine whether the SSE self-efficacy of patients with melanoma and their partners is affected by their partners' comfort and support during skin examinations.

METHODS

100 patient-partner dyads completed a 25-item sociodemographic questionnaire. Fifty-two partners attended an education session with the patient on skin examinations and the early detection of melanoma. All patients attended the education session.

FINDINGS

Having their partners attend the education session, as well as being supportive and comfortable with skin examinations, significantly predicted patients' self-efficacy with SSEs. In addition, male patients were found to be significantly more comfortable with partner-assisted skin examinations and reported feeling more supported by their partner than female patients.

Targeted Melanoma Screening: Risk Self-Assessment and Skin Self-Examination Education Delivered During Mammography of Women

Background

Melanoma, which is the sixth most common cancer in women, is visible on the surface of the skin; therefore, self-screening (skin self-examination [SSE]) may be beneficial.

Methods

A convenience sample of women undergoing mammography was sequentially assigned by week into this two-arm targeted melanoma screening intervention. Both groups saw an informational poster and received a brochure promoting risk self-identification and SSE education. One group received an additional 1-week SSE reminder. Participants completed baseline and 1- and 3-month follow-up surveys assessing SSE performance, identifying a concerning mole, scheduling a dermatology appointment, and anxiety due to the program. Performance of SSE between groups was compared using χ² analysis. The electronic medical record was reviewed for diagnosis of concerning moles.

Results

At 1 month, 384 of 420 (91.4% retention) women completed the survey. Of those, 311 (80.9%) performed SSE. Of those who performed SSE, 54 (14%) found a concerning mole at either 1 or 3 months. At 3 months, 346 (82.4% retention) women completed the survey. The number of women who performed SSE did not differ between groups at 1 month (χ² = 1.64, P = .17) or 3 months (χ² = 1.58, P = .12). Seven melanomas were found among 34 women who identified a concerning mole; examination of 4.8 women yielded one melanoma. Anxiety was low with a median score of 9.5 (range = 0–42.9).

Conclusions

Introducing melanoma risks and SSE education during mammography was feasible and did not demonstrate harms; thus, there is an opportunity to reach a large, at-risk population with limited burden for the participant and clinics.

Development and initial validation of the Self-Efficacy for Skin Self-Examination Scale in a Canadian sample of patients with melanoma

PURPOSE

Melanoma is the deadliest type of skin cancer, although survival rates are high if detected early. Skin self-examination (SSE) is a health behaviour that can lead to early detection of melanoma and more positive health outcomes. Self-efficacy for SSE is a potential predictor of engaging in skin self-exams. However, no standardized measures of self-efficacy for SSE are currently available. The present study reports on the development and initial validation of a measure assessing self-efficacy for SSE.

METHOD

Based on a literature review, including previous studies assessing this construct, the research team developed 9 items capturing confidence in one's ability to conduct SSE. Items were subsequently revised by the research team and two dermatologists, resulting in the elimination of 4 items and modifications to the response options. The final 5-item Self-Efficacy for SSE scale was administered to a sample of 242 melanoma patients recruited from local hospitals. We assessed the scale's factor structure through exploratory factor analysis and the internal consistency with Cronbach's alpha. Scale scores were correlated with intentions to perform SSE, physician support for SSE, skin cancer-specific distress, general distress, and sociodemographic variables to assess convergent and divergent validity.

RESULTS

The scale was found to be unifactorial with adequate model fit, have acceptable internal consistency (Cronbach alpha = 0.74), and initial evidence of convergent and divergent validity, as indicated by the scale correlating with physicians' support for SSE (r = 0.30, p < 0.01), intention to perform SSE (r_s = 0.21, p < 0.01) and a weak correlation with general distress (r = 0.15, p < 0.05).

CONCLUSIONS

Pending future research corroborating these findings, this measure has potential for use by nurses and other health professionals in follow-up care to identify individuals at risk for low self-efficacy for SSE requiring more targeted educational SSE interventions.

Health Behaviour Changes of Cutaneous Melanoma Survivors in Slovenia - A Qualitative Study

Introduction

Most data related to cutaneous melanoma survivors' health behaviour comes from epidemiological studies and is predominantly concerned with safe-sun behaviour and self-examination. Data regarding other changes of health behaviour are scarce and so are qualitative studies in this realm. The aim of our research is to acquire insight into the experiences of patients with cutaneous melanoma in Slovenia. How did they react to the diagnosis, which changes did they introduce in their health behaviour and how do they assess the role of family doctors?

Methods

Using the qualitative approach of collective case reports, a demographically diverse group of patients with different forms and stages of cutaneous melanoma was selected. Semi-structured interviews conducted by a psychologist were recorded and transcribed verbatim. For data processing, the approach of Qualitative Content Analysis was applied.

Results

We integrated interviewees' experiences after the diagnosis of cutaneous melanoma in several subcategories: either they did not introduce any changes or they mentioned changing their habits when exposed to the sun and performing skin self-examination; they also emphasized their ways of dealing with stress and raising awareness about melanoma among family members and friends. The role of family doctors in the prevention and care appears unclear; even contradictory.

Conclusion

We obtained insight into the experiences of Slovenian patients with cutaneous melanoma. The interviewees prioritised safe behaviour in the sun, strengthening of psychological stability and raising awareness about melanoma. Findings will be used in the creation of a structured questionnaire for national epidemiological survey.

Clustering of prevention behaviours in patients with high-risk primary melanoma

OBJECTIVE

Because melanoma patients are at high risk of further disease, we aimed to study their melanoma prevention behaviours.

METHODS

In a large cohort of patients newly diagnosed with high-risk melanoma in Queensland, Australia, we assessed clustering of preventive behaviours using latent class analysis. We assessed associated factors with prevalence proportion ratios (PPRs) and 95% confidence intervals (CIs) estimated by Poisson regression and also if preventive behaviour was associated with better tumour prognosis at diagnosis.

RESULTS

Among 789 primary melanoma patients (57% male; 21% with previous melanoma), we identified 4 different behaviour clusters: "no/ low prevention" (34% of cohort), "sun protection only" (25%), "skin checks only" (25%), and "sun protection and skin checks" (17%). Prevalence of clusters differed between males and females and also the component behaviours. Preventive behaviours were associated with having skin that burned and past cutaneous cancer, and for males, combined sun protective and skin checking behaviour was associated with higher education and non-smoking. In patients with no past history of cutaneous cancer, males in the "skin checks only" cluster had significantly reduced chances of a thick (poor prognosis) melanoma (PPR = 0.79, 95% CI 0.68, 0.91) and females in the "sun protection and skin checks" cluster were significantly less likely to have an ulcerated melanoma (PPR = 0.85, 95% CI 0.74, 0.98) compared with the "no/ low prevention" cluster.

CONCLUSION

These findings allow tailoring of preventive advice to melanoma patients to reduce their risk of future primary and recurrent disease.

Development and preliminary validation of the physician support of skin self-examination scale

Skin self-examination (SSE) is a crucial preventive health behaviour in melanoma survivors, as it facilitates early detection. Physician endorsement of SSE is important for the initiation and maintenance of this behaviour. This study focussed on the preliminary validation of a new nine-item measure assessing physician support of SSE in melanoma patients. English and French versions of this measure were administered to 188 patients diagnosed with melanoma in the context of a longitudinal study investigating predictors and facilitators of SSE. Structural validity was investigated using exploratory factor analysis conducted in Mplus and convergent and divergent validity was assessed using bivariate correlations conducted in spss. Results suggest that the scale is a unidimensional and reliable measure of physician support for SSE. Given the uncertainty regarding the optimal frequency of SSE for at-risk individuals, we recommend that future psychometric evaluations of this scale consider tailoring items according to the most up-to-date research on SSE effectiveness.

[Patterns of access to information on protection against UV during the Brazilian summer: is there such a thing as the "summer effect"?]

Internet search patterns associated with "windows" of collective interest have been increasingly investigated in the field of public health. This article sets out to identify search patterns relating to the quest for information on skin protection after the perception of excessive exposure to UV radiation - the so-called "summer effect" as it is commonly referred to in Brazil. To calculate the number of hits on the Brazilian National Cancer Institute website - a renowned source of information resources on prevention - log analyzer software was used to measure the volume of hits on specific content pages. The pages on skin protection and self-examination (pages of interest) were monitored over a 48-month period. It was seen that, although the monthly average of hits on pages of interest revealed statistically significant annual growth, the results for the analysis of variance showed no significant differences between the number of hits in the summer compared with other months (p = 0.7491). In short, the perception of intense exposure to the summer sun did not encourage further interest to search for information on prevention.

The role of patient education and physician support in self-efficacy for skin self-examination among patients with melanoma

OBJECTIVE

This project aims to elucidate the relationships between skin self-examination (SSE), perceived physician support of SSE, and self-efficacy for SSE among melanoma patients.

METHODS

A longitudinal study of patients diagnosed with melanoma was conducted over the span of 18 months. Participants filled out questionnaires at four assessment points and participated in an SSE education about the early signs of melanoma.

RESULTS

Among the 242 patients enrolled, the level of self-efficacy for SSE was 23% higher immediately after the educational intervention (p<.001) and the increase was retained three months (p<.001) and twelve months later (p<.001). Additionally, a one-way repeated measures ANOVA revealed that the perceived physician support of SSE positively corresponded to the level of patient self-efficacy with higher patient-reported physician support being related to higher self-efficacy (p=.001).

CONCLUSION

Patient education and perceived physician support of SSE are positively associated with patients' level of self-efficacy.

PRACTICE IMPLICATIONS

Physicians caring for melanoma survivors should be aware that, both SSE education and patients' perception of high physician support of SSE may be associated with higher self-efficacy for checking one's own skin for signs of cancer recurrence.

A state of the science on influential factors related to sun protective behaviors to prevent skin cancer in adults

Skin cancer rates have risen over the past decades, making it imperative that adults understand the need for protection from sun exposure. Though some risk factors have been identified as predictive for skin cancers, there is a lack of synthesized information about factors that influence adults in their decisions to engage in sun protective behaviors. The purpose of this paper is to present the current state of the science on influential factors for sun protective behaviors in the general adult population. A rigorous literature search inclusive of a generally White, Caucasian, and non-Hispanic adult population was performed, and screening yielded 18 quantitative studies for inclusion in this review. Findings indicate that modifiable and non-modifiable factors are interdependent and play a role in sun protective behaviors. This study resulted in a proposed conceptual model for affecting behavioral change in sun protection including the following factors: personal characteristics, cognitive factors, family dynamics, and social/peer group influences. These factors are introduced to propose tailored nursing interventions that would change current sun protective behavior practice. Key implications for nursing research and practice focus on feasibility of annual skin cancer screening facilitated by advanced practice nurses, incorporating the identified influential factors to reduce skin cancer risk and unnecessary sun exposure.

Skin Examination Practices Among Melanoma Survivors and Their Children

Many professional organizations recommend skin self-examination (SSE) as a tool for early detection of malignancy among melanoma survivors, a growing population that is at increased risk for new or recurrent melanoma. This study examined the frequency and correlates of SSE use among melanoma survivors. Additionally, we assessed skin exam use among children of survivors, who are at elevated lifetime risk for the disease. The California Cancer Registry was used to identify melanoma survivors, who were contacted, screened for eligibility, and invited to participate in a survey. The survey, administered by mail, web, or telephone, assessed a broad range of topics related to melanoma prevention in high-risk families. The present study focuses on skin examination practices of survivors and their children and potential correlates of these practices. Among a sample of 316 melanoma survivors, fewer than one in five participants performed monthly skin self-exams, a lower rate than that observed in previous studies. Although greater family history of melanoma, use of skin protection strategies, and the perceived severity of melanom were associated with more frequent use of skin self-exams, these relationships disappeared in adjusted analyses. Participants reported unexpectedly frequent use of skin examinations for their children despite the lack of professional guidelines for this practice. Interventions are needed to improve skin self-examination practices among melanoma survivors and to counsel parents about optimal melanoma prevention strategies for their children.

A Qualitative Study of Quality of Life Concerns following a Melanoma Diagnosis

The goal of this study was to identify a relevant and inclusive list of quality of life issues among long-term survivors of melanoma. Individuals diagnosed with stage I-III cutaneous melanoma and had survived 1-5 years, ages 18-65 years at diagnosis, were recruited. Five focus groups were conducted with 33 participants in total. Discussions centered on participants' experiences at diagnosis, as well as ongoing physical, emotional, and social concerns, and behavioral changes since diagnosis. The majority of participants reported shock, fear, and feeling overwhelmed at the time of diagnosis. Some reported lingering physical concerns, including pain, numbness, and lymphedema, while a few reported no lasting issues. Emotional concerns were common, with most reporting anxiety. Several also noted feeling lonely and isolated. Social concerns included alteration of activities to avoid sun exposure, issues with family communication, and frustration with the lack of appreciation of the seriousness of melanoma by others. Finally, while many participants reported changes to their sun exposure and UV-protection behaviors, some reported little to no change. The shared experiences among participants in this study confirm the unique nature of melanoma and the need for interventions designed to improve the health and quality of life of melanoma survivors.

The Berlin Social Support Scales: Validation of the Received Support Scale in a Canadian sample of patients affected by melanoma

The purpose of this study was to examine the reliability and validity of the Received Support Scale of the Berlin Social Support Scales in a Canadian sample of English and French language melanoma patients (N = 137). Participants received a skin self-examination education and completed self-report questionnaires. Exploratory factor analyses, reliability analyses, and independent samples t-tests were conducted. Findings support the unidimensionality of the Received Support Scale of the Berlin Social Support Scales. The psychometric similarities of the French and English versions of the scale, its strong internal consistency, as well as its convergent and discriminant validity support the use of the Received Support Scale of the Berlin Social Support Scales in patients with melanoma.

Self-efficacy and comfort with partner-assisted skin examination in patients receiving follow-up care for melanoma

The objective of this study was to examine the role of interpersonal variables on melanoma survivors' self-efficacy for performing skin self-examinations (SSEs) during melanoma follow-up care. Specifically, the impact of comfort with partner assistance for SSE, SSE support received from one's partner, general partner support, relationship satisfaction, as well as partner attendance at a SSE education session, were examined. One hundred and thirty-seven patients with melanoma between the ages of 18 and 70 years, who also reported being involved in a romantic relationship, received a standardized education on SSE, and completed self-report questionnaires. Results indicate that SSE support and SSE comfort predicted patients' SSE self-efficacy. Partner attendance at the SSE education moderated the relationship between SSE comfort and SSE self-efficacy. In other words, SSE self-efficacy was found to be affected by partner attendance at the SSE education only in cases where the patient reported lower levels of comfort having his or her partner assist with SSE. Results highlight the importance of partner involvement in SSE education, as well as patient comfort with a partner's assistance during skin examinations. Findings inform potential modifications to the follow-up care provided to melanoma survivors by demonstrating the importance of partner involvement in SSE education.

Sun Exposure and Protection Behaviors among Long-term Melanoma Survivors and Population Controls

Introduction: Melanoma is considered a generally preventable cancer, with excessive ultraviolet radiation (UVR) exposure being a strong causal factor. UVR exposure following a melanoma diagnosis can be modified to reduce risk of second primary melanomas. The goal of this study was to compare measures of UVR exposure and protection behaviors between long-term melanoma survivors and controls.Methods: Participants from a previously conducted case-control study were recruited for a cross-sectional survey. Melanoma cases were 25 to 59 years old at diagnosis; controls were age and sex matched. Participants were asked about UVR exposure and protection measures used in the past year, and comparisons between melanoma survivors and controls were conducted using logistic regression models, adjusting for potential confounders.Results: A total of 724 (62.0%) long-term melanoma survivors and 660 (59.9%) controls completed the follow-up survey. Melanoma survivors were significantly less likely to report high sun exposure on a typical weekday [OR, 0.72 (0.55-0.94)], sunburns [OR, 0.40 (0.30-0.53)], or indoor tanning [OR, 0.20 (0.09-0.44)] than controls; however, high sun exposure on a typical weekend day was similar. Report of optimal sun protection behaviors was higher in melanoma survivors compared with controls. However, a few melanoma survivors reported indoor tanning, 10% reported intentionally seeking sun to tan, and 20% reported sunburns.Conclusions: Although long-term melanoma survivors reported healthier UVR exposure and protection behaviors compared with controls, a sizeable proportion still reported elevated sun exposure, sunburns, and suboptimal UVR protection behaviors.Impact: Opportunities remain for improving sun protection to reduce future melanoma risk among melanoma survivors. Cancer Epidemiol Biomarkers Prev; 26(4); 607-13. ©2017 AACR.

Communication about melanoma and risk reduction after melanoma diagnosis

BACKGROUND

Melanoma patients are advised to perform regular risk-reduction practices, including sun protection as well as skin self-examinations (SSEs) and physician-led examinations. Melanoma-specific communication regarding family risk and screening may promote such behaviors. To this end, associations between patients' melanoma-specific communication and risk reduction were examined.

METHODS

Melanoma patients (N = 169) drawn from a population-based cancer registry reported their current risk-reduction practices, perceived risk of future melanoma, and communication with physicians and relatives about melanoma risk and screening.

RESULTS

Patients were, on average, 56 years old and 6.7 years' post diagnosis; 51% were male, 93% reported "fair/very fair" skin color, 75% completed at least some college, and 22% reported a family history of melanoma. Patients reported varying levels of regular (always/nearly always) sun protection: sunscreen use (79%), shade seeking (60%), hat use (54%), and long-sleeve shirt use (30%). Only 28% performed thorough SSE regularly, whereas 92% reported undergoing physician-led skin examinations within the past year. Participants who were female, younger, and had a higher perceived risk of future melanoma were more likely to report past communication. In adjusted analyses, communication remained uniquely associated with increased sunscreen use and SSE.

CONCLUSIONS

Encouraging melanoma patients to have a more active role in discussions concerning melanoma risk and screening with relatives and physicians alike may be a useful strategy to promote 2 key risk-reduction practices post melanoma diagnosis and treatment. Future research is needed to identify additional strategies to improve comprehensive risk reduction in long-term melanoma patients.

Skin cancer prevention practices among malignant melanoma survivors: a systematic review

PURPOSE

This systematic review was conducted to evaluate and summarize the existing literature on prevalence of ultraviolet radiation (UVR) exposure, sun protection, and screening behaviors among individuals diagnosed with malignant melanoma (MM).

METHODS

The search was performed in PubMed, CINAHL, PsycINFO, ScienceDirect, EMBASE, and ERIC from inception of each database through July 2014. Studies were included if (1) individuals diagnosed with MM were the primary sample, (2) measured UVR exposure, primary and secondary preventive behaviors, (3) original research communication that constitutes an entire set of empirical data, (4) observational design, and (5) English peer-reviewed. Studies were excluded if (1) all of the inclusion criteria were not met and (2) duplicates, conference abstracts, editorials, news, letters to the editor, comments, reviews, feature articles, white papers, and guidelines.

RESULTS

The search resulted in 255 articles that were screened for relevance; however, only 15 articles met all of the inclusion criteria. Most of the studies were cross-sectional (n = 10), used self-administered surveys (n = 8), and were conducted in North America (n = 10). The sample sizes ranged considerably, but were mostly Caucasian (n = 6) and included a higher proportion of women (n = 8). Evidence demonstrated that individuals with MM still engaged in sunbathing, indoor tanning, and reported sunburns. Moreover, survivors reported inadequate levels of both sun protection and skin self-examinations.

CONCLUSIONS

The findings highlight the need for intensifying intervention strategies to reduce the risk of new primary MMs in this group. Future research should increase in rigor and include more diverse populations and regions.

Predictors of Sun-Protective Practices among Iranian Female College Students: Application of Protection Motivation Theory

PURPOSE

Given the importance of sun protection in the prevention of skin cancer, this study was designed to determine predictors of sun-protective practices among a sample of Iranian female college students based on protection motivation theory (PMT) variables.

MATERIALS AND METHODS

In this cross-sectional study, a total of 201 female college students in Iran University of Medical Sciences were selected. Demographic and PMT variables were assessed with a 67-item questionnaire. Multiple linear regression was used to identify demographic and PMT variables that were associated with sun-protective practices and intention.

RESULTS

one percent of participants always wore a hat with a brim, 3.5% gloves and 15.9% sunglasses while outdoors. Only 10.9% regularly had their skin checked by a doctor. Perceived rewards, response efficacy, fear, self-efficacy and marital status were the five variables which could predict 39% variance of participants intention to perform sun-protective practices. Also, intention and response cost explained 31% of the variance of sun-protective practices.

CONCLUSIONS

These predictive variables may be used to develop theory-based education interventions interventions to prevent skin cancer among college students.

Awareness, Attitude, and Adherence to Preventive Measures in Patients at High Risk of Melanoma. A Cross-Sectional Study on 185 Patients

Melanoma is potentially curable if diagnosed at its earliest stages and treated properly. The best approaches for reducing deaths due to melanoma are primary and secondary prevention. The objective of this study is to evaluate patient awareness of the risk factors for developing melanoma and attitudes toward its prevention. Also, this study aims to assess observance of recommended preventive measures and to identify possible factors associated with a low adoption of these measures. This cross-sectional study based on an online questionnaire included 185 consecutively enrolled subjects at risk of developing melanoma monitored in a pigmented lesion unit in Valencia (Spain). Level of knowledge, attitude, and observance of preventive measures were evaluated. Statistical analysis was carried out using contingency tables, chi-squared test, and Spearman correlation. Out of those who reported practicing skin self-examination, only 24.1 % performed it in the optimal way. A better attitude was observed in low-risk patients (r = -0.28, p < 0.01). Being female (p < 0.01), aged 18-35 (p = 0.02), fair-haired (p = 0.02), having skin phototype I-II (p < 0.01), and a suitable attitude (p = 0.05) and knowledge (p < 0.01) were related to a better use of sunscreens and avoidance of sun exposure. Knowledge was inversely associated with age (p = 0.01). Despite the high level of knowledge and positive attitude, inadequate practice of compliance with recommended primary and secondary preventive measures was observed in our risk population.

Skin protection behaviour and sex differences in melanoma location in patients with multiple primary melanomas

BACKGROUND/OBJECTIVES

Previous studies have shown that sunscreen usage, sun-protection measures and self-examination rates in patients with single primary melanomas (SPM) are similar to that in the general population. This study hypothesises that these rates would be different in a population with multiple primary melanomas (MPM). We further hypothesise that there would be a sex difference in melanoma location in patients with MPM. The objectives of this study were to determine skin protection measures, self-examinations and melanoma location in a cohort of patients with MPM.

METHODS

A survey was conducted on 137 patients with MPM examining their sun-protection measures, skin self-examination rates and medical and phenotypic characteristics. These data were combined with a review of their medical records to examine the patients' skin cancer history.

RESULTS

Patients with MPM had higher rates of skin self-evaluation (74% vs 22%), sunscreen usage (70% vs 45%) and other sun-protection measures (95% vs 46%) than has been published for patients with a history of a SPM. We have also shown that women have a higher risk of developing melanomas on their arms (p < 0.01) and lower legs (p < 0.05) than men.

CONCLUSIONS

This report showed the rates of skin self-examination, sunscreen usage and other sun-protection methods in patients with MPM is higher than in studies of patients with SPM. It also highlighted sex differences in terms of melanoma location for patients with MPM. Further studies to examine the cause of the differences in these forms of protective behaviour could help improve the utilisation of these important preventative measures in all patients.

Effects of web-based intervention on risk reduction behaviors in melanoma survivors

PURPOSE

Melanoma is the most severe form of skin cancer, and survivors of melanoma carry increased risk of additional melanoma diagnosis. Multiple methods exist for primary and secondary prevention of melanoma in survivors. This study tested a web-based family communication intervention to improve these preventive behaviors in melanoma families.

METHODS

Families (a survivor, at least one first-degree relative and a parent) were randomized either to receive the intervention package or to serve as comparison families. We assessed melanoma prevention behaviors in each cohort member before and after the intervention. The intervention was a web-based multicomponent intervention focused on increasing family communication and exchange of risk information.

RESULTS

Results indicated that, compared to comparison survivors, intervention survivors improved their skin self-examination and their sun protection behaviors significantly from before to after intervention.

CONCLUSION

These data support the use of web-based interventions for behavioral changes in survivors and allow for consideration of dissemination of this successful intervention. These data have implications for interventions that can help cancer families deal with issues of risk and illness.

IMPLICATIONS FOR CANCER SURVIVORS

These data indicate that survivors can benefit from exposure to a website that helps direct their future health behaviors.

Coping with melanoma-related worry: a qualitative study of the experiences and support needs of patients with malignant melanoma

AIMS AND OBJECTIVES

To explore the patients' experience of having malignant melanoma, their related support needs and the processes that lead to these needs being met.

BACKGROUND

The number of patients attending surveillance clinics after a diagnosis of malignant melanoma is increasing. In the UK specialist nurses provide support to patients, but little evidence exists about the nature of patients' support needs or their experience of having melanoma. Melanoma has often been researched within general cancer studies, yet the support needs of melanoma patients may be different from those of patients with other skin cancers or tumour types.

DESIGN

A Grounded Theory Approach was used to guide sampling, data collection and analysis.

METHODS

In-depth interviews were conducted with eleven patients who where purposively sampled. Transcripts were read several times, coded and categorised using the constant comparative method. Emergent categories were discussed with participants.

RESULTS

Three emergent categories related to a core category of melanoma-related worry which formed a substantive theory about the strategies patients use to control this. Participants reported needing to have their concerns believed by others prior to and after diagnosis. They discussed discerning whom to share their concerns with depending upon who they felt would not perceive assisting them as being burdensome. They also sought ways to reassure themselves.

CONCLUSIONS

Patients need to have their fear and worries acknowledged by others. This includes nurses, healthcare professionals and family members. Patients will also use self-examination and the absence of symptoms to reassure themselves.

RELEVANCE TO CLINICAL PRACTICE

Nurses play key roles throughout the patient's care; therefore they need to be sensitive to the fact that patients may consider them a primary source of support. When teaching self-examination it is important that nurses discuss that this may ease worry and aid coping.

Is surviving enough? Coping and impact on activities of daily living among melanoma patients with lymphoedema

We assessed the impact of lymphoedema (defined as ≥ 10% limb volume change) on quality of life (QOL), ability to perform activities of daily living (ADLs) and coping in 277 melanoma patients. Limb volume was measured prospectively, pre-operatively and every 3-6 months for 18 months post-operatively using a perometer. Three questionnaires were administered to measure QOL, coping and impact on ADLs. Statistical analyses were conducted using longitudinal logistic regression models. At 18 months, the cumulative incidence of lymphoedema was 31% in patients with upper extremity nodal basin treatment and 40% in lower extremity nodal basin treatment patients. Patients with lower extremity lymphoedema reported lower QOL scores than those with upper extremity lymphoedema. Over 18 months, both groups with mild and moderate lymphoedema showed improvement in coping [odds ratio (OR): 6.67, 95% confidence interval (CI): 3.30-13.47] and performance of ADLs (OR: 7.46, CI: 3.38-16.47). Over the course of 18 months, men were found to have poorer coping scores than women (OR: 2.91, CI: 1.35-6.27). Lymphoedema was associated with improvement in coping over time (P = 0.08) and a higher reported interference with ADLs (OR: 2.53, CI: 1.29-4.97). Patient education about lymphoedema at the time of surgical consent may improve self-efficacy and coping ability. Effective management of lymphoedema may improve patient QOL and reduce interference with ADLs.

Red meat and fruit intake is prognostic among patients with localized cutaneous melanomas more than 1mm thick

BACKGROUND

As the 10-year mortality for localized cutaneous melanoma more than 1.00 mm thick approaches 40% following complete resection, non-therapeutic interventions that can supplement recommended active surveillance are needed. Although guidelines recommending nutrition, physical activity and tobacco cessation for cancer survivors have been published, data describing their associations with melanoma survivorship are lacking.

METHODS

Analysis of modifiable lifestyle behaviors collected on the 249 cases with melanomas more than 1.00 mm thick enrolled in the Connecticut Case-Control Study of Skin Self-Examination study was conducted. Independent associations with melanoma-specific survival were evaluated through Cox proportional hazards modeling adjusting for age, gender, Breslow thickness, ulceration and the presence of microsatellites. Independently significant variables were then combined into a single model and backwards elimination was employed until all remaining variables were significant at p<0.05.

RESULTS

Following adjustment for age, Breslow thickness and anatomic site of the index melanoma, daily fruit consumption was associated with improved melanoma-specific survival (HR=0.54; 95% CI: 0.34-0.86) whereas at least weekly red meat consumption was associated with worse outcomes (HR=1.84; 95% CI: 1.02-3.30). Natural red (HR=0.44; 95% CI: 0.22-0.88) or blond (HR=0.52; 95% CI: 0.29-0.94) hair were also favorably prognostic. Higher fish consumption was of borderline significance for improved survival only when considered independently (HR=0.65; 95% CI: 0.40-1.05); no association was seen following adjustment for red meat and fruit consumption (p>0.10).

CONCLUSIONS

Dietary choices at the time of diagnosis are associated with melanoma-specific survival in patients with melanomas more than 1.00 mm thick. Further validation of our findings in larger cohorts with repeated post-diagnostic measures is warranted to further evaluate whether dietary modification during the survivorship period can improve melanoma-specific survival.

Surviving cutaneous melanoma: a clinical review of follow-up practices, surveillance, and management of recurrence

The number of melanoma survivors in the United States continues to steadily increase 2.6% per year, while death rates have remained stable over time. Although controversy exists regarding optimal surveillance strategies, recommendations for clinical monitoring are based on tumor stage, tumor phenotype, likelihood of recurrence, prognosis, risk factors, psychosocial impact of disease, and patient well-being. Management guidelines for recurrent disease depend on the type of recurrence: local, satellite/in-transit, regional, or distant metastasis. This article is a current review of the literature concerning melanoma survivorship.