Skin Cancer: Healthcare Settings and Providers

The Community Guide review expands on the USPSTF review by evaluating a broader range of providers and by including system approaches not limited to providers.

• Only two assessed reducing UV exposure or increasing sun-protective behavior, and results were inconsistent.
• Several studies showed improvements in intermediate outcomes, such as changes in knowledge, attitudes, beliefs, and intentions of providers.

The following outlines evidence gaps from these reviews of interventions to prevent skin cancer: Community-Wide, Mass Media Campaigns (archived); Community-Wide, Multicomponent Interventions (archived); Education and Policy Approaches for Healthcare Settings and Providers; Education and Policy Approaches in Child Care Centers (archived); Education and Policy Approaches in Primary School Settings (archived); Education and Policy Approaches in Secondary Schools and Colleges (archived); Education and Policy Approaches in Outdoor Occupational Settings (archived); Education and Policy Approaches in Outdoor Recreational Settings (archived); Interventions Targeting Children’s Parents and Caregivers.

Design and Analysis Considerations

• All of the designs included in this review have important strengths and weaknesses.
• Additional diverse approaches are worth pursuing, in terms of study design and execution, and with attention both to internal and external validity.
• Consistently rigorous analytic methods are needed, and future studies should control for relevant confounders, such as risk levels and weather conditions.

Description of Target Population and Context

• Several reports in this area of research did not contain basic descriptions of the intervention or population.
• In many instances, the distribution of the population by race and ethnicity or sun sensitivity was not described.
• Many of the settings could have been better described.
• Better descriptions are needed of annual UV exposure in the places in which studies were conducted.
• Better descriptions of these important issues would help assess the likely applicability of the findings or explain any variability of effects.

Description of Intervention

• It was difficult to disentangle what specific intervention components were, or how much emphasis there was on primary prevention (versus early detection) or on promoting use of sunscreen versus on covering-up or sun-avoidance behaviors.
• Further information is needed on which attributes of the interventions contribute most to intervention effectiveness or ineffectiveness (e.g., do policy components or education components contribute more to intervention effectiveness; what are the central “active ingredients” in complex interventions).
• Describing intervention characteristics in greater detail might also help practitioners replicate successes.

Duration of Interventions and Length of Follow up

• Given the seasonality of sun-protective behaviors and the importance of encouraging habitual as opposed to short-term behavior change, a longer follow-up is crucial.

Intervention Quality

• An encouraging trend can be seen in increasing use of formative research and pre-testing of interventions before they are implemented.
• Mediating factors deserve greater attention and need to be correlated with behavior changes. To date, few studies in this area of research have reported on both mediating factors and behavioral or health outcomes.
• A need also exists to develop measures of the effects of environmental and policy change strategies. Few interventions addressed policy or environmental changes and in those that did, the effects of the policy or environmental components could not be disentangled from other aspects of the intervention.

Measurement of Exposure

• Few studies reported process evaluation data, which can help to assess how much of the intervention was actually implemented.
• Improvement in this area would be helpful, especially for interventions of longer duration and increased complexity.

Measurement of Outcomes

• More behavioral and health outcomes need to be examined.
  • Given recent concerns about the adequacy of sunscreen as a sole protective strategy, additional behavioral and health outcomes should also be measured.
  • Outcomes need to be similar to evaluate effectiveness.
  • Measurement of specific sun-protective behaviors is important.
  • More interventions with a greater focus on covering up and sun- avoidance, and a decreased emphasis on sunscreen use are needed.
• Given recent research findings on the effectiveness of sunscreens, more detailed research on sunscreen use is needed.
  • Are higher SPF sunscreens being used?
  • Does sunscreen use extend the amount of time out in the sun?
• How do different sun-protective behaviors interact (e.g., does seeking shade make wearing sunscreen or a hat unnecessary)?
• Further work is needed to increase consistency between at least a core set of behavior change measures that can be used to compare and contrast study results.

Research Needs and Work in Progress

The field of behavior change for skin cancer prevention has progressed significantly, but important areas for further advancement exist. As outlined above, these include design, measurement, better description of interventions, development of a better understanding of how environmental and policy interventions work, and studies in multiethnic populations. The use of new communication technology and international collaborations can make significant contributions in these areas. The team hopes that the availability of systematic reviews that identify both progress to date and the remaining gaps will help to reduce the gaps in available research.

• Specific Research Issues. Although most of the evidence gaps described above were general and could explain why most setting specific categories did not produce sufficient evidence to determine effectiveness, a few research issues were specific to the setting or target group.

• Interventions for Secondary Schools. More studies are needed to examine sun-protective behaviors of adolescents and young adults, and to determine what kind of approach might work best in this population, especially given the low baseline prevalence of sun-protective behaviors.

• Interventions in Occupational Settings. Studies that target the most common outdoor occupational workers mail carriers, agricultural workers, landscapers, horticulturists, foresters, construction workers, telephone line workers, commercial fishery workers, land surveyors and mappers, oil field workers, amusement park attendants, and athletes are needed.

• Interventions in Healthcare Settings. Almost all studies in this category examined the counseling behavior of the provider and not the patient. More studies that examine the behavioral or health outcome of the end user the patient are needed. In this small subset of studies, the provider was most often a physician or a physician-in-training, but studies examining the role of the nonphysician provider would help identify whether counseling skills to change behavior might be better suited for providers with the time and skills, such as a nurse or a health educator. Additionally, more studies are needed to examine healthcare system studies oriented directly to patients.

• Interventions for Parents and Caregivers. Studies are needed to examine the effect of interventions on nonparental caregivers, as it is becoming increasingly common for children to be cared for by nonparental caregivers while both parents are at work outside the home.

• Interventions in Multicomponent Community Settings. Approaches to better define the “active ingredients” (i.e., the most important components that contribute to the success of these interventions) would be helpful, as would determining the applicability of these interventions to the U.S. population.

Task Force on Community Services. Recommendations to prevent skin cancer by reducing exposure to ultraviolet radiation. American Journal of Preventive Medicine 2004;27(5):467-70.

Centers for Disease Control and Prevention. Preventing skin cancer. Findings of the Task Force on Community Preventive Services on reducing exposure to ultraviolet light. MMWR 2003;52(RR-15):1-12. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5215a1.htm.

Hill D. Skin cancer prevention: a commentary. American Journal of Preventive Medicine 2004;27(5):482-3.

Koh HK, Geller AC. Skin cancer prevention comes of age. American Journal of Preventive Medicine 2004;27(5):484-5.

Task Force on Community Services, Zaza S, Briss PA, Harris KW. Cancer. In: The Guide to Community Preventive Services: What Works to Promote Health? Atlanta (GA): Oxford University Press; 2005:143-87.

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Dolan N, Ng J, Martin G, Robinson J, Rademaker A. Effectiveness of a skin cancer control educational intervention for internal medicine housestaff and attending physicians.Journal of General Internal Medicine 1997;12: 531-6.

Gerbert B, Wolff M, Tshcann J, McPhee S, Caspers N, Martin M, Saulovich A. Activating patients to practice skin cancer prevention: Response to mailed materials from physicians versus HMOs. American Journal of Preventive Medicine 1997;13: 214-20.

Gooderham M, Guenther L. Impact of a sun awareness curriculum on medical students’ knowledge, attitudes and behavior. Journal of Cutaneous Medicine and Surgery 1999;3:182-7.

Harris J. Can internet based continuing medical education improve physicians’ skin cancer knowledge and skills? Journal of General Internal Medicine 2001;16:50-6.

Harris J, Salasche S, Harris R. Using the internet to teach melanoma management guidelines to primary care physicians. Journal of Evaluation in Clinical Practices 1999;5:199-211.

Johnson E., Lookingbill D. Suncreen use and sun exposure. Archives of Dermatology 1984;120:727-31.

Liu K, Barankin B, Howard J, Guenther L. One-year follow-up on the impact of a sun awareness curriculum on medical students’ knowledge, attitudes and behaviors.Journal of Cutaneous Medicine and Surgery 2001;5:193-200.

Mayer J, Eckhardt L, Stepanski B, Sallis J, Elder J, Slymen D, Creeh L, Graf G, Palmer R, Rosenberg C, Souvignier S. Promoting skin cancer prevention counseling by pharmacists. American Journal of Public Health 1998;88(7):1096-9.

Mayer J, Slymen D; Eckhardt L, Rosenberg C, Stepanski B, Creech L, Palmer. Skin cancer prevention counseling by pharmacists: Specific outcomes of an intervention trial. Cancer Detection & Prevention 1998;22:367-75.

McCormick L, Masse L, Cummings, Burke C. Evaluation of a skin cancer prevention module for nurses: Change in knowledge, self-efficacy and attitudes. American Journal of Health Promotion 1999;13:282-9.

Mikkileni R, Weinstock M, Goldstein M, Dube C, Rossi J. Impact of the basic skin cancer triage curriculum on providers skin cancer control practices. Journal of General Internal Medicine 2000;16:302-7.

Palmer R, Mayer J, Eckhardt L, Sallis J. Promoting sunscreen in a community drugstore. American Journal of Public Health 1998;88:681.

Electronic searches for literature were conducted in MEDLINE, PsycINFO, and CINAHL (nursing and allied health). The team also reviewed the references listed in all retrieved articles, and consulted with experts on the systematic review development team and elsewhere, including seeking published and unpublished articles in a sun protection listserve sponsored by the Environmental Protection Agency. The team included journal articles and governmental reports. The initial literature search on the topic was conducted in 1999, and the search was updated monthly until June 2000.

To be included, identified studies had to:

• Evaluate a specified population-based intervention for the prevention of skin cancer
• Be published in English from 1966 to June 2000
• Involve primary prevention of skin cancer (i.e., studies promoting screening were excluded because the effectiveness of screening was uncertain according to the USPSTF (see www.ahrq.gov/clinic/uspstf/uspsskca.htm)
• Evaluate effectiveness and assess at least one of the outcomes specified on the team’s analytic frameworks and/or provide information on one or more of the following domains: applicability, other effects (i.e., harms or side effects), economic evaluation, or barriers to intervention implementation
• Be conducted in an established market economy*
• Be a primary study rather than, for example, a guideline or review

Studies of effectiveness or applicability also required that the study compare a group of people who had been exposed to the intervention with a group of people who had not been exposed or who had been less exposed. (The comparisons could be concurrent or in the same group over time. Studies in the other domains could be with or without a comparison.)

Search Strategy

1 skin neoplasms/or skin cancer.tw.
2 melanoma/
3 carcinoma, basal cell/or carcinoma, squamous cell/
4 nevus/or nevi.tw.
5 keratosis/
6 actinic keratoses.tw.
7 (sun damage or photodamage).tw. or skin aging/
8 solar keratoses.tw.
9 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8
10 primary prevention/or prevention.mp. [mp _title, abstract, registry number word, mesh subject heading]
11 pc.fs.
12 knowledge/or knowledge, attitudes, practice/or knowledge.mp. [mp _ title, abstract, registry number word, mesh subject heading]
13 awareness/or awareness.mp. [mp _ title, abstract, registry number word, mesh subject heading]
14 (attitude or attitude or attitudes).mp. [mp _ title, abstract, registry number word, mesh subject heading]
15 public policy/or policy.mp. [mp _ title, abstract, registry number word, mesh subject heading]
16 health promotion/or health education/
17 behavior/or behavior:.mp. [mp _ title, abstract, registry number word, mesh subject heading]
18 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17
19 9 and 18
20 19 not screen:.tw,hw.
21 19 and screen:.tw,hw. and primary prevention.mp. [mp _ title; abstract, registry number word, mesh subject heading]
22 20 or 21
23 (sunburn: or suntan: or tanning).mp. [mp _ title, abstract, registry number word, mesh subject heading]
24 ultraviolet rays/or ultraviolet radiation.mp. [mp _title, abstract, registry number word, mesh subject heading]
25 (sun exposur: or sun protect: or sun safety or solar protect: or solar exposur:).mp. [mp _ title, abstract, registry number word, mesh subject
heading]
26 sunlight/or protective clothing/or protective clothing.mp. [mp _ title, abstract, registry number word, mesh subject heading]
27 sunscreening agents/
28 23 or 24 or 25 or 26 or 27
29 18 and 28
30 29 not screen:.tw,hw.
31 29 and screen:.tw,hw. and primary prevention.mp. [mp _ title, abstract, registry number word, mesh subject heading]
32 30 or 31
33 22 or 32
34 limit 33 to English language
35 limit 34 to human

Evidence-Based Cancer Control Programs (EBCCP)

Find programs from the EBCCP website that align with this systematic review. (What is EBCCP?)