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Enhancing Skin Cancer Screening Through Behavioral Intervention

Enhancing Skin Cancer Screening Through Behavioral Intervention In this issue of JAMA Dermatology, Janda and colleagues1 report on the results of a randomized clinical trial (RCT) of a video-based behavioral intervention aimed at increasing clinical skin examination (CSE) among men 50 years or older in Queensland, Australia. At the 7-month follow-up, men who received informational brochures were as likely as the video intervention group to have obtained a CSE (53% vs 56%, respectively). However, the video intervention group was more likely than controls to self-report a whole-body rather than a partial or spot CSE (35% vs 27%, respectively), to have been asked by their physicians to return for a follow-up examination, to have been diagnosed as having a malignant neoplasm, and to have had surgical management of a lesion. Previously, several large studies conducted in Australia and the United Kingdom concluded that without whole-body examination, many melanoma and nonmelanoma diagnoses would be missed.2,3 Janda and colleagues also report on other correlates of CSE uptake and skin cancer diagnosis. This work possesses many notable methodologic strengths. These include the detailed report of an RCT supplemented by 2 prior publications describing other aspects of the study, enrollment of men 50 years or older (a group known to be at high risk of melanoma and death from melanoma4), random selection from the Queensland compulsory electoral roll with a respectable 37% response rate for the baseline telephone survey, a relatively large sample size (n = 929 at baseline), inclusion of participants with lower education and income levels than in many other trials, the use of the Health Belief Model5 as a theoretical framework, an intervention targeted specifically toward older men based on formative qualitative interviews, 94% sample retention at the 7-month follow-up, telephone interviewers independent from the research team and blinded to intervention condition, 83% corroborative medical reports for the 59% of men who consented to share their medical reports, and listing with the Australian New Zealand Clinical Trials Registry. Although outweighed by numerous strengths, the authors note that because they focused on analysis of CSEs corroborated by a physician, they may have overestimated the skin cancer diagnosis rate because men who did not consent to medical reporting were less likely to report suspicious lesions but were not included in some analyses. It would have also been interesting to know whether intervention participants were any more likely to seek screening from dermatologists than general practitioners. The authors had previously reported that Australian general practitioners are excellent at diagnosing skin cancer, but this may not be the case in some other countries. As the authors point out, the impact of the intervention may have been less than it could have been because the participant pool was already fairly motivated. At baseline, 81% of participants reported that a physician had ever checked any part of their skin for skin cancer, and 39% had had a whole-body CSE within the last year. These high baseline rates among the Queensland population are presumably due to decades of media- and community-based skin cancer awareness campaigns, conducted in part by Janda and colleagues. Among US adults, however, rates of ever having had a CSE have been found to be approximately 15% to 17%,6,7 and large community-based skin cancer screening interventions are uncommon. Also in relation to patient motivation, there was a trend toward men in the intervention group who reported CSE and having watched the DVD more than once being more likely to report a whole-body CSE than those who did not watch it or watched it 1 time. Presumably men who watched the DVD 1 or more times were also more likely than men who did not watch the video to report CSE at all. This would suggest a potential dose-response relationship; however, 50% of men who denied watching the video still reported obtaining a whole-body CSE. A major challenge in health behavior research and practice is not only adherence to the recommended behavioral outcome (ie, skin cancer screening) but also adherence to the recommended intervention (ie, viewing the video or brochure), even among seemingly motivated populations. The study eligibility criteria of English language proficiency and access to a DVD player may limit generalizability of the findings somewhat. Socioeconomic factors such as these have been associated with skin cancer screening.8 For example, in the current study, individuals with a regular general practitioner were more likely to self-report a CSE than others. Interesting questions for future research would be for which subpopulations were the interventions most effective, particularly when comparing by education, socioeconomic status, ethnicity, and so on, and how to optimize the interventions for other cultures, such as non-English speakers and US or European populations. Although skin cancer rates are lower in nonwhite groups, racial and ethnic minorities are not immune from the disease and sometimes face higher mortality rates relative to incidence.8 It has been recommended that interventions designed to address health disparities be culturally appropriate, inexpensive, user-friendly, appropriate for individuals with low health literacy levels, easily disseminated, as well as address access to care, utilize tailoring, and involve the community when possible.9-11 In addition, when developing interventions for an older population, it is important to keep in mind potential declines in cognitive abilities and a tendency toward a greater reliance on making decisions based on emotions as a result of such declines.12 In terms of future directions, the self-administered video and informational brochure would likely be highly disseminable and cost-effective as interventions to increase skin examinations. Both seem to have increased CSE and thus skin cancer detection over baseline rates. The interventions could also be updated and enhanced over time to potentially increase effects, although the video would require more effort to update than the brochure. Both interventions may be able to be enhanced with additional intervention components, such as personalized tailoring based on participant individual characteristics (eg, marital status, skin cancer risk factors, attitudes, and behaviors), supportive counseling, and/or other empirically validated behavioral strategies. The current experimental intervention was a DVD-based video. This could be replaced or supplemented with additional technologies, such as a web-based interactive intervention, a smartphone “app,” and so on. Of course, additional technologies may have more or less appeal and potential effectiveness and disseminability across populations. Janda and colleagues point to the cost-effectiveness of screening men 50 years or older for skin cancer. Yet, there are apparently no studies examining the cost-effectiveness of interventions to increase skin cancer screening. Interventions such as the authors’, with low dissemination costs, would likely be very cost-effective, and potentially more so among populations with lower baseline screening rates, such as US men. Among the US Medicare population, nonmelanoma skin cancer is one of the most costly cancers to treat because of its high prevalence.13 It has been estimated that cancer incidence would decline by 19% and cancer mortality would decline by 29% in the United States if evidence-based behavior change interventions were put into practice.14 Despite the publication of several rigorous RCTs, such as this one, demonstrating promising intervention effects on skin cancer screening and diagnosis rates, screening the general population has not been widely recommended in most countries owing to the lack of RCTs focusing on skin cancer mortality.15 However, several recent large observational trials have provided additional empirical support for widespread population skin cancer screening programs (eg, the German SCREEN project16) in reducing mortality. Janda and colleagues note that routine CSE could place a burden on health care systems and increase detection of relatively indolent cancers. Related issues are whether individuals have access to screening by a health care provider and whether patients have insurance coverage for treatment of the malignant neoplasms detected. Australia and several other countries have universal health care coverage, and the United States recently adopted the Patient Protection and Affordable Care Act, which may provide the population with more access than was available previously. However, such health care resources are far from unlimited. In conclusion, Janda and colleagues have made a major contribution to the work of identifying efficacious and cost-effective interventions to increase engagement in skin cancer screening behavior, particularly among groups at high risk of morbidity and mortality, such as men 50 years or older. Skin cancer is the most prevalent of all cancers and is increasing in incidence. Skin cancer screening is efficacious and cost-effective in detecting thinner and, therefore, more curable skin cancers. However, engagement in skin cancer screening is suboptimal in many groups, even among seemingly motivated high-risk populations. Thus, more research is needed on interventions to improve skin cancer screening and intervention dissemination approaches, especially among high-risk populations, such as older men and individuals with a personal or family history of skin cancer. Several behavioral interventions have been developed and have demonstrated promise in enhancing skin cancer screening. Future research on skin cancer screening might benefit from assessing the impact of interventions on specific socioeconomic subpopulations and the incorporation of new technologies. Such approaches might enhance needed dissemination of efficacious interventions to the public. Back to top Article Information Corresponding Author: Carolyn J. Heckman, PhD, Cancer Prevention and Control Program, Fox Chase Cancer Center, 333 Cottman Ave, P4163, Philadelphia, PA 19111 (carolyn.heckman@fccc.edu). Published Online: February 19, 2014. doi:10.1001/jamadermatol.2013.9311. Conflict of Interest Disclosures: None reported. Funding/Support: This work was supported by National Institutes of Health (NIH) grant P30CA006927 (Cancer Center grant). Role of the Sponsor: The NIH had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. References 1. Janda M, Youl P, Neale R, et al. Clinical skin examination outcomes after a video-based behavioral intervention: analysis from a randomized clinical trial [published online February 19, 2014]. JAMA Dermatol. doi:10.1001/jamadermatol.2013.9313.Google Scholar 2. Aldridge RB, Naysmith L, Ooi ET, Murray CS, Rees JL. The importance of a full clinical examination: assessment of index lesions referred to a skin cancer clinic without a total body skin examination would miss one in three melanomas. Acta Derm Venereol. 2013;93(6):689-692.PubMedGoogle ScholarCrossref 3. Terrill PJ, Fairbanks S, Bailey M. Is there just one lesion? the need for whole body skin examination in patients presenting with non-melanocytic skin cancer. ANZ J Surg. 2009;79(10):707-712.PubMedGoogle ScholarCrossref 4. Joosse A, Collette S, Suciu S, et al. Superior outcome of women with stage I/II cutaneous melanoma: pooled analysis of four European Organisation for Research and Treatment of Cancer phase III trials. J Clin Oncol. 2012;30(18):2240-2247.PubMedGoogle ScholarCrossref 5. Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the Health Belief Model. Health Educ Q. 1988;15(2):175-183.PubMedGoogle ScholarCrossref 6. Coups EJ, Geller AC, Weinstock MA, Heckman CJ, Manne SL. Prevalence and correlates of skin cancer screening among middle-aged and older white adults in the United States. Am J Med. 2010;123(5):439-445.PubMedGoogle ScholarCrossref 7. Lakhani NA, Shaw KM, Thompson T, et al. Prevalence and predictors of total-body skin examination among US adults: 2005 National Health Interview Survey. J Am Acad Dermatol. 2011;65(3):645-648.PubMedGoogle ScholarCrossref 8. Hernandez C, Mermelstein RJ. A conceptual framework for advancing melanoma health disparities research. Arch Dermatol. 2009;145(12):1442-1446.PubMedGoogle ScholarCrossref 9. Cooper LA, Hill MN, Powe NR. Designing and evaluating interventions to eliminate racial and ethnic disparities in health care. J Gen Intern Med. 2002;17(6):477-486.PubMedGoogle ScholarCrossref 10. Friedman DB, Kao EK. A comprehensive assessment of the difficulty level and cultural sensitivity of online cancer prevention resources for older minority men. Prev Chronic Dis. 2008;5(1):A07.PubMedGoogle Scholar 11. Geller J, Swetter SM, Leyson J, Miller DR, Brooks K, Geller AC. Crafting a melanoma educational campaign to reach middle-aged and older men. J Cutan Med Surg. 2006;10(6):259-268.PubMedGoogle Scholar 12. Isaacowitz DM, Choi Y. Looking, feeling, and doing: are there age differences in attention, mood, and behavioral responses to skin cancer information? Health Psychol. 2012;31(5):650-659.PubMedGoogle ScholarCrossref 13. Housman TS, Williford PM, Feldman SR, et al. Nonmelanoma skin cancer: an episode of care management approach. Dermatol Surg. 2003;29(7):700-711.PubMedGoogle ScholarCrossref 14. Graham AL, Abrams DB. Reducing the cancer burden of lifestyle factors: opportunities and challenges of the Internet. J Med Internet Res. 2005;7(3):e26.PubMedGoogle ScholarCrossref 15. US Preventive Services Task Force. Screening for skin cancer: recommendation statement, 2009. http://www.uspreventiveservicestaskforce.org/uspstf09/skincancer/skincanrs.htm. Accessed July 30, 2012. 16. Katalinic A, Waldmann A, Weinstock MA, et al. Does skin cancer screening save lives? an observational study comparing trends in melanoma mortality in regions with and without screening. Cancer. 2012;118(21):5395-5402.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Dermatology American Medical Association

Enhancing Skin Cancer Screening Through Behavioral Intervention

Heckman, Carolyn J.
JAMA Dermatology , Volume 150 (4) – Apr 1, 2014
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References (16)

Publisher
American Medical Association
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Copyright © 2014 American Medical Association. All Rights Reserved.
ISSN
2168-6068
eISSN
2168-6084
DOI
10.1001/jamadermatol.2013.9311
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24553600
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Abstract

In this issue of JAMA Dermatology, Janda and colleagues1 report on the results of a randomized clinical trial (RCT) of a video-based behavioral intervention aimed at increasing clinical skin examination (CSE) among men 50 years or older in Queensland, Australia. At the 7-month follow-up, men who received informational brochures were as likely as the video intervention group to have obtained a CSE (53% vs 56%, respectively). However, the video intervention group was more likely than controls to self-report a whole-body rather than a partial or spot CSE (35% vs 27%, respectively), to have been asked by their physicians to return for a follow-up examination, to have been diagnosed as having a malignant neoplasm, and to have had surgical management of a lesion. Previously, several large studies conducted in Australia and the United Kingdom concluded that without whole-body examination, many melanoma and nonmelanoma diagnoses would be missed.2,3 Janda and colleagues also report on other correlates of CSE uptake and skin cancer diagnosis. This work possesses many notable methodologic strengths. These include the detailed report of an RCT supplemented by 2 prior publications describing other aspects of the study, enrollment of men 50 years or older (a group known to be at high risk of melanoma and death from melanoma4), random selection from the Queensland compulsory electoral roll with a respectable 37% response rate for the baseline telephone survey, a relatively large sample size (n = 929 at baseline), inclusion of participants with lower education and income levels than in many other trials, the use of the Health Belief Model5 as a theoretical framework, an intervention targeted specifically toward older men based on formative qualitative interviews, 94% sample retention at the 7-month follow-up, telephone interviewers independent from the research team and blinded to intervention condition, 83% corroborative medical reports for the 59% of men who consented to share their medical reports, and listing with the Australian New Zealand Clinical Trials Registry. Although outweighed by numerous strengths, the authors note that because they focused on analysis of CSEs corroborated by a physician, they may have overestimated the skin cancer diagnosis rate because men who did not consent to medical reporting were less likely to report suspicious lesions but were not included in some analyses. It would have also been interesting to know whether intervention participants were any more likely to seek screening from dermatologists than general practitioners. The authors had previously reported that Australian general practitioners are excellent at diagnosing skin cancer, but this may not be the case in some other countries. As the authors point out, the impact of the intervention may have been less than it could have been because the participant pool was already fairly motivated. At baseline, 81% of participants reported that a physician had ever checked any part of their skin for skin cancer, and 39% had had a whole-body CSE within the last year. These high baseline rates among the Queensland population are presumably due to decades of media- and community-based skin cancer awareness campaigns, conducted in part by Janda and colleagues. Among US adults, however, rates of ever having had a CSE have been found to be approximately 15% to 17%,6,7 and large community-based skin cancer screening interventions are uncommon. Also in relation to patient motivation, there was a trend toward men in the intervention group who reported CSE and having watched the DVD more than once being more likely to report a whole-body CSE than those who did not watch it or watched it 1 time. Presumably men who watched the DVD 1 or more times were also more likely than men who did not watch the video to report CSE at all. This would suggest a potential dose-response relationship; however, 50% of men who denied watching the video still reported obtaining a whole-body CSE. A major challenge in health behavior research and practice is not only adherence to the recommended behavioral outcome (ie, skin cancer screening) but also adherence to the recommended intervention (ie, viewing the video or brochure), even among seemingly motivated populations. The study eligibility criteria of English language proficiency and access to a DVD player may limit generalizability of the findings somewhat. Socioeconomic factors such as these have been associated with skin cancer screening.8 For example, in the current study, individuals with a regular general practitioner were more likely to self-report a CSE than others. Interesting questions for future research would be for which subpopulations were the interventions most effective, particularly when comparing by education, socioeconomic status, ethnicity, and so on, and how to optimize the interventions for other cultures, such as non-English speakers and US or European populations. Although skin cancer rates are lower in nonwhite groups, racial and ethnic minorities are not immune from the disease and sometimes face higher mortality rates relative to incidence.8 It has been recommended that interventions designed to address health disparities be culturally appropriate, inexpensive, user-friendly, appropriate for individuals with low health literacy levels, easily disseminated, as well as address access to care, utilize tailoring, and involve the community when possible.9-11 In addition, when developing interventions for an older population, it is important to keep in mind potential declines in cognitive abilities and a tendency toward a greater reliance on making decisions based on emotions as a result of such declines.12 In terms of future directions, the self-administered video and informational brochure would likely be highly disseminable and cost-effective as interventions to increase skin examinations. Both seem to have increased CSE and thus skin cancer detection over baseline rates. The interventions could also be updated and enhanced over time to potentially increase effects, although the video would require more effort to update than the brochure. Both interventions may be able to be enhanced with additional intervention components, such as personalized tailoring based on participant individual characteristics (eg, marital status, skin cancer risk factors, attitudes, and behaviors), supportive counseling, and/or other empirically validated behavioral strategies. The current experimental intervention was a DVD-based video. This could be replaced or supplemented with additional technologies, such as a web-based interactive intervention, a smartphone “app,” and so on. Of course, additional technologies may have more or less appeal and potential effectiveness and disseminability across populations. Janda and colleagues point to the cost-effectiveness of screening men 50 years or older for skin cancer. Yet, there are apparently no studies examining the cost-effectiveness of interventions to increase skin cancer screening. Interventions such as the authors’, with low dissemination costs, would likely be very cost-effective, and potentially more so among populations with lower baseline screening rates, such as US men. Among the US Medicare population, nonmelanoma skin cancer is one of the most costly cancers to treat because of its high prevalence.13 It has been estimated that cancer incidence would decline by 19% and cancer mortality would decline by 29% in the United States if evidence-based behavior change interventions were put into practice.14 Despite the publication of several rigorous RCTs, such as this one, demonstrating promising intervention effects on skin cancer screening and diagnosis rates, screening the general population has not been widely recommended in most countries owing to the lack of RCTs focusing on skin cancer mortality.15 However, several recent large observational trials have provided additional empirical support for widespread population skin cancer screening programs (eg, the German SCREEN project16) in reducing mortality. Janda and colleagues note that routine CSE could place a burden on health care systems and increase detection of relatively indolent cancers. Related issues are whether individuals have access to screening by a health care provider and whether patients have insurance coverage for treatment of the malignant neoplasms detected. Australia and several other countries have universal health care coverage, and the United States recently adopted the Patient Protection and Affordable Care Act, which may provide the population with more access than was available previously. However, such health care resources are far from unlimited. In conclusion, Janda and colleagues have made a major contribution to the work of identifying efficacious and cost-effective interventions to increase engagement in skin cancer screening behavior, particularly among groups at high risk of morbidity and mortality, such as men 50 years or older. Skin cancer is the most prevalent of all cancers and is increasing in incidence. Skin cancer screening is efficacious and cost-effective in detecting thinner and, therefore, more curable skin cancers. However, engagement in skin cancer screening is suboptimal in many groups, even among seemingly motivated high-risk populations. Thus, more research is needed on interventions to improve skin cancer screening and intervention dissemination approaches, especially among high-risk populations, such as older men and individuals with a personal or family history of skin cancer. Several behavioral interventions have been developed and have demonstrated promise in enhancing skin cancer screening. Future research on skin cancer screening might benefit from assessing the impact of interventions on specific socioeconomic subpopulations and the incorporation of new technologies. Such approaches might enhance needed dissemination of efficacious interventions to the public. Back to top Article Information Corresponding Author: Carolyn J. Heckman, PhD, Cancer Prevention and Control Program, Fox Chase Cancer Center, 333 Cottman Ave, P4163, Philadelphia, PA 19111 (carolyn.heckman@fccc.edu). Published Online: February 19, 2014. doi:10.1001/jamadermatol.2013.9311. Conflict of Interest Disclosures: None reported. Funding/Support: This work was supported by National Institutes of Health (NIH) grant P30CA006927 (Cancer Center grant). Role of the Sponsor: The NIH had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. References 1. Janda M, Youl P, Neale R, et al. Clinical skin examination outcomes after a video-based behavioral intervention: analysis from a randomized clinical trial [published online February 19, 2014]. JAMA Dermatol. doi:10.1001/jamadermatol.2013.9313.Google Scholar 2. Aldridge RB, Naysmith L, Ooi ET, Murray CS, Rees JL. The importance of a full clinical examination: assessment of index lesions referred to a skin cancer clinic without a total body skin examination would miss one in three melanomas. Acta Derm Venereol. 2013;93(6):689-692.PubMedGoogle ScholarCrossref 3. Terrill PJ, Fairbanks S, Bailey M. Is there just one lesion? the need for whole body skin examination in patients presenting with non-melanocytic skin cancer. ANZ J Surg. 2009;79(10):707-712.PubMedGoogle ScholarCrossref 4. Joosse A, Collette S, Suciu S, et al. Superior outcome of women with stage I/II cutaneous melanoma: pooled analysis of four European Organisation for Research and Treatment of Cancer phase III trials. J Clin Oncol. 2012;30(18):2240-2247.PubMedGoogle ScholarCrossref 5. Rosenstock IM, Strecher VJ, Becker MH. Social learning theory and the Health Belief Model. Health Educ Q. 1988;15(2):175-183.PubMedGoogle ScholarCrossref 6. Coups EJ, Geller AC, Weinstock MA, Heckman CJ, Manne SL. Prevalence and correlates of skin cancer screening among middle-aged and older white adults in the United States. Am J Med. 2010;123(5):439-445.PubMedGoogle ScholarCrossref 7. Lakhani NA, Shaw KM, Thompson T, et al. Prevalence and predictors of total-body skin examination among US adults: 2005 National Health Interview Survey. J Am Acad Dermatol. 2011;65(3):645-648.PubMedGoogle ScholarCrossref 8. Hernandez C, Mermelstein RJ. A conceptual framework for advancing melanoma health disparities research. Arch Dermatol. 2009;145(12):1442-1446.PubMedGoogle ScholarCrossref 9. Cooper LA, Hill MN, Powe NR. Designing and evaluating interventions to eliminate racial and ethnic disparities in health care. J Gen Intern Med. 2002;17(6):477-486.PubMedGoogle ScholarCrossref 10. Friedman DB, Kao EK. A comprehensive assessment of the difficulty level and cultural sensitivity of online cancer prevention resources for older minority men. Prev Chronic Dis. 2008;5(1):A07.PubMedGoogle Scholar 11. Geller J, Swetter SM, Leyson J, Miller DR, Brooks K, Geller AC. Crafting a melanoma educational campaign to reach middle-aged and older men. J Cutan Med Surg. 2006;10(6):259-268.PubMedGoogle Scholar 12. Isaacowitz DM, Choi Y. Looking, feeling, and doing: are there age differences in attention, mood, and behavioral responses to skin cancer information? Health Psychol. 2012;31(5):650-659.PubMedGoogle ScholarCrossref 13. Housman TS, Williford PM, Feldman SR, et al. Nonmelanoma skin cancer: an episode of care management approach. Dermatol Surg. 2003;29(7):700-711.PubMedGoogle ScholarCrossref 14. Graham AL, Abrams DB. Reducing the cancer burden of lifestyle factors: opportunities and challenges of the Internet. J Med Internet Res. 2005;7(3):e26.PubMedGoogle ScholarCrossref 15. US Preventive Services Task Force. Screening for skin cancer: recommendation statement, 2009. http://www.uspreventiveservicestaskforce.org/uspstf09/skincancer/skincanrs.htm. Accessed July 30, 2012. 16. Katalinic A, Waldmann A, Weinstock MA, et al. Does skin cancer screening save lives? an observational study comparing trends in melanoma mortality in regions with and without screening. Cancer. 2012;118(21):5395-5402.PubMedGoogle ScholarCrossref

Journal

JAMA Dermatology – American Medical Association

Published: Apr 1, 2014

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