- Email: [email protected]
Melanoma awareness and self-examination practices: Results of a United States survey
Melanoma awareness and self-examination practices: Results of a United States survey Donald R. Miller, ScD, a, b, c Alan C. Geller, RN, MPH, a, b Stephen W. Wyatt, DMD, MPH, d Allan Halpern, MD, e J. B. Howell, MD, f Clay Cockerell, MD, f Barbara A. Reilley, Phi), RN, d Barbara A. Bewerse, MN, MPH, d Darrell Rigel, MD,g Lawrence Rosenthal, Phi), h Rex Amonette, MD, h Ting Sun, MPH, a Ted Grossbart, PhD, a Robert A. Lew, PhD, a and Howard K. Koh, MD, M P H a, b Boston and Newton, Massachusetts; Atlanta, Georgia;
Philadelphia, Pennsylvania; Dallas, Texas; New York, New York; and Schaumburg, Illinois Background: Skin cancers are common and there has been a dramatic increase in their incidence, particularly melanoma. However, little is known about awareness of melanoma and early detection practices in the general U.S. population. Objective: In 1995, the American Academy of Dermatology increased their efforts to promote awareness of melanoma. This study was conducted to document current knowledge of melanoma and self-examination practices. Methods: In February 1995, a telephone survey was conducted in a nationally representative sample of 1001 persons at least 18 years of age (3% margin of error) that included questions on knowledge, attitudes, and practices regarding early detection of melanoma. Results: Almost 42% of those surveyed were unaware of melanoma, and only 26% of those who were aware could identify its specific signs. Most recognized at least one common risk factor for melanoma (e.g., sun exposure, fair skin). However, many did not distinguish melanoma from other skin cancers in terms of risk factors, signs of early disease, and body site distribution. The lowest measures of melanoma knowledge and attitudes were found among those who are male, nonwhite, and parents, and those with the lowest level of education and income. More than half (54%) did not conduct a self-examination. This practice was most frequently reported by women, white persons, and the elderly, as well as those with a greater knowledge of melanoma. Conclusion: Ourresearch documents deficiencies in knowledge and practices related to early detection of melanoma in the general U.S. population and supports the need for public education about melanoma. (J Am Acad Dermatol 1996;34:962-70.)
Skin cancer, the most common form of cancer in the United States, will be newly diagnosed in more than one million Americans during 1996.1 MelaFrom the Departments of Dermatology and Medicine and the Cancer Prevention and Control Center, Boston University School of Medicinea; Boston University School of Public Healthb; Health Research Associates, NewtonC; Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, Atlantaa; Department of Dermatology, University of Pennsylvania, Philadelphiae; Department of Dermatology, University of Texas, Dallasf; Department of Dermatology, New York University, New Yorkg; and American Academy of Dermatology, Schaurnburg. h Accepted for publication Feb. 5, 1996. Reprint requests: Donald R. Miller, Health Research Associates, 128 Chestnut St., Newton, MA 02165-2539. Copyright i996 by the American Academy of Dermatology, Inc. 0190-9622/96 $5.00 + 0
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noma represents only 3% to 4% of these diagnoses, but it accounts for the greatest number of deaths from skin cancer. In 1995, more than 7000 Americans died of this cancer and more than 38,000 received a new diagnosis of melanoma. 2-4 Furthermore, melanoma incidence and mortality have increased dramatically over the past two decades with rates of increase ranked among the highest of all cancers. 35 Early, thin melanoma lesions can usually be seen by patients, and surgical excision of these lesions almost always leads to cure without further treatment.6, 7 Hence, in theory, increasing public awareness and promoting early detection and treatment should help many people to have melanoma discovered and removed at an earlier stage and thereby re-
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duce mortality from melanoma. 8' 9 Skin self-examination (SSE) for cancer could enhance early detection of melanoma, and many organizations, including the American Academy of Dernmtology (AAD), advocate the practice of SSE and provide educational materials with pictorial instructions to foster and instruct in the examination. 9' 10 Little is known, however, about who practices SSE and what the public knows about SSE and melanoma prevention and early detection. Melanoma/Skin Cancer Detection and Prevention Mouth is an annual campaign by the AAD to increase awareness of melanoma and other skin cancers and to promote their early detection. In 1995, the AAD added a special program to promote "Melanoma Self-examination D a y " ("Melanoma Monday") and to raise public awareness of melanoma, encourage physician visits for examination of pigmented lesions, and promote SSE. Shortly before the publicity for this program began, a national survey was conducted to document current knowledge of melanoma and self-examination practices. The results of that survey are presented in this report. METHODS The First Melanoma Awareness and Skin Examination survey was conducted in February 1995 by the Opinion Research Corporation (Princeton, N.J.), in collaboration with the AAD and Public Communications Inc. (PCI). The telephone survey was conducted among a national probability sample of 1001 adults, 18 years of age and older, riving in private households in the United States. The final sample consisted of 1001 respondents, providing an overall margin of error of 3.0%. The survey included 10 questions on familiarity with the term melanoma, early signs of melanoma, self-examination practices (including reasons for not examining the skin and examination frequency), warning signs and factors associated with increased risk of the development of melanoma, and most common body sites of melanoma. In addition, information was obtained on nine demographic and socioeconomic variables (sex, age, race/ethnicity, education, income, marital status, children in household, and state of residence). The frequency distributions of survey responses for each of the questions on melanoma knowledge and practice of SSE were examined overall and with stratification according to the demographic and socioeconomic variables. Initially, differences in response frequencies between groups were evaluated with chi-square tests) 1 Subsequently, multivariate analysis was conducted by means of logistic regression to adjust for all of the demo-
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graphic and socioeconomic variables simultaneously. 12 All test results presented in this report come from logistic regression analysis with a specific category of response to a knowledge or practice question as the dependent variable and dichotomous terms (dummy variables) for the demographic and socioeconomic variables; all models included terms for sex (male, female), age (<25 years, 25 to 44 years, 45 to 64 years, 65 years and older), race/ethnicity (white, other), education (<12 years, high school graduate, some college or technical school, advanced degree), annual household income (<$20,000, $20,000$39,999, $40,000-$74,999, $75,000 and higher), marital status (never married, currently married, prior marriage [divorced, separated, or widowed]), children younger than 18 years old in the household (yes/no), and area of residence (northeast, north central, south, west). All analyses were conducted with statistical software from the SAS Institute (Cary, N.C.) 13 RESULTS Demographic and socioeconomic characteristics of the 1001 participants in the survey (Table I) are comparable to measures for the general U.S. adult population from the census and other national surveys. 14 Participants resided in 43 states evenly distributed throughout the country. The sample consisted of nearly equal numbers of men and women, two thirds of respondents were between 25 and 65 years of age, and most (90%) had at least a high school education. Almost 81% of respondents were non-Hispanic Caucasians. M e l a n o m a awareness and k n o w l e d g e Table II presents responses to survey questions on melanoma awareness and knowledge. When asked: "Can you tell me what melanoma is?", nearly 42% of respondents were unaware of the term, 55% knew it to be a type of cancer, and 34% specifically knew it to be a type of skin cancer. When participants were read a list of melanoma risk factors, most (95%) recognized at least one as something that "can increase risk of melanoma." Affirmative responses were particularly frequent for sun-related risk factors (82.3% for history of sun exposure and 58.4% for bad sunburns in childhood), and relatively infrequent for moles (41.3% for having many moles and 28.1% for being born with moles) and for two of the three skin sensitivity (phenotype) questions (63.3% for fair skin, 27.8% for red hair and blue eyes, and 21.7% for freckles). When asked to name the early signs of melanoma, 37% said that they did not know, and only 26% correctly identified specific signs of
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Table I. Characteristics of the 1001 participants
Table II. Awareness and knowledge of
in the 1995 M d a n o m a Awareness and Self-Examination Survey
melanoma among the 1001 participants in the 1995 Melanoma Awareness and Self-Examination Survey
Variable Sex Female Male Race/Ethnicity White, non-Hispanic Black, non-Hispanic Hispanic Other Age (yr) <25 25-44 45-64 ->65 Area of residence Northeast North Central South West Education >12 High school graduate Some college or technical school Advanced degrees Unknown Annual household income <$20,000 $20,000-$39,999 $40,000-$74,999 ->$75,000 Unknown Martial status Currently married Divorced, separated, widowed Never married Children in household Yes No
{
%
Can you tell me what melanoma is ?
51.3 48.7 80.9 11.1 7.0 1.0 14.7 42.7 25.5 17.1 21.0 22.4 35.7 20.9 9.4 34.5 25.8 29.4 0.9 18.4 31.3 22.7 8.6 19.0 57.3 21.9 20.8 31.4 68.6
Some kind of skin cancer 34.1% Some kind of cancer 20.5% Other 3.7% Don't know 41.7% Which of the following do you believe can increase risk of melanoma?* History of sun exposure 82.3% Bad sunburns in childhood 58.4% Having lots of moles 41.3% Being born with moles 28.1% Fair skin 63.3% Red hair and blue eyes 27.8% Freckles 21.7% Family history of melanoma 67.4% Other 0.5% None of these, don't know 5.0% Can you name early signs of melanoma? A change in a mole 21.8% A new mole 4.5% A sore that won't heal 5.1% A lump 2.2% Any type of change in the skin 4.4% Blotchy skin or dark spots 15.0% Redness 2.0% Discoloration 3.9% Skin rash 2.2% Dry, itchy, or scaly skin 0.8% Other 1.3% Don't know 36.7% Where is melanoma most likely to occur?* Head and shoulders 51.7% Arms and legs 35.5% Chest and stomach 5.4% Back 10.3% Anywhere exposed to the sun 12.3% Don't know 17.7% *Response categoriesare not mutuallyexclusive;respondentsmay choosemorethanone.
early melanoma (a change in a mole or a new mole); most of the other responses were not specific for melanoma (e.g., blotchy skin).6 When asked where on the body they thought melanoma was most likely to occur, most reported head and shoulders, arms and legs, or "sun-exposed areas," more suggestive of nonmelanoma skin cancer. 15 Only 15% included body areas such as the back, chest, and stomach, which are often covered and may be more difficult to examine.7
Skin self-examination practices Responses to SSE questions are shown in Table HI. When asked "Do you ever closely examine
yourself for signs of skin cancer or melanoma?", 46% reported that they did, and most of them (85%) said that they examined their skin at least monthly. However, only 26% reported looking specifically for changes in moles or new moles; most said that they looked for any changes in the skin or its pigmentation. Only 29% of self-examiners said that they learned to examine their skin from medical professionals and only 8% learned from a dermatologist. The most frequent source of knowledge about SSE was the news media, and 16% learned from a friend or relative. We also asked those who exam-
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Table III. Self-examination for skin cancer among the 1001 participants in the 1995 Melanoma Awareness and Self-Examination Survey Do you ever closely examine yourself for signs of skin cancer or melanoma?
Yes* (45.9%; n = 479) How often do you examine your skin? Once a year at most Every 2 to 6 months Once a month Weekly Daily What do you look for on your skin? Things that weren't there before Changes in moles New moles Color or pigment changes Sore that won't heal Bumps and lumps Dry, itchy, or scaly skin Redness Skin rash Blotchy skin or dark spots Other
4.9% 10.6% 22.4% 24.5% 37.6% 34.2% 21.7% 4.1% 16.2% 4.5% 6.8% 3.3% 0.8% 1.1% 2.9% 3.4%
No* (53.5%; n = 518) Why don't you examine your skin? Never think about it Didn't know I should Didn't know what to look for Wouldn't know what to do Would notice, don't need to Unlikely to get melanoma Not in sun enough Have enough to worry about Don't have time Don't see well enough Frightened to find something Other Don't know
22.7% 14.0% 11.2% 0.7% 9.9% 8.0% 4.4% 2.2% 2.6% 0.6% 0.7% 9.7% 13.4%
Where did you leam that you shouM examine your skin for cancer?
Dermatologist Doctor Health services School
7.7% 18.8% 3.1% 8.8%
News media Family member or friend Other Don't know
28.1% 15.7% 11.7% 6.0%
*Four respondents (0.5%) did not answer the question.
ined their skin what they would do if they noticed what they thought might be melanoma; 91% said that they would promptly call or see their doctor (14.8% said they would contact a dermatologist, 76.7% said they would contact another type of doctor); only 2% said that they would not act promptly (0.8% would tell their doctor at their next medical visit, 1.3% would wait to see if it goes away or changes). The remaining 54% of respondents (n = 518) who never examined their skin for cancer were asked why they did not. The responses were approximately equally distributed into four groups: (1) low awareness ("never think about it"); (2) little knowledge ("did not know that I should," "did not know what to look for," "did not know what to do if something were found"); (3) denial of risk ("did not need to," "unlikely to get melanoma," "not in sun enough"); and (4) other ("had enough to worry about," "don't see well enough," "don't have enough time," "frightened to find something"), including simply not knowing why they did not examine themselves.
Variations in knowledge according to sociodemographic factors Melanoma awareness varied substantially by several of the factors (Table IV). Knowing the term at all a n d knowing that it is a kind of skin cancer were both substantially more common among women, white persons, and adults older than 25 years of age, although there was little variation in knowledge among the three age groups above 25 years. Awareness also increased progressively with increasing education and with increasing annual income up to a level of $40,000 per year. Apparent variation in melanoma awareness by marital status was not statistically significant after adjustment for age and other factors, but adults with children living in their households had less awareness of melanoma. Variation in melanoma awareness by area of residence was modest and not statistically significant. Other measures of melanoma knowledge, including knowledge of risk factors and early signs, tended to follow similar patterns with higher levels of knowledge among women, white persons, older
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Table I V . Awareness of m e l a n o m a according to sociodemographic factors a m o n g the 1001 participants in the 1995 M e l a n o m a Awareness and Self-examination Survey Can you tell me what melanoma is? (%)
Overall By sex Female Male By race White Black By age (yr) 18-24 25-44 45-64 ->65 By education <12 yr High school graduate Some college College graduate By income <$20,000 $20,000-$39,999 $40,000-$74,999 ->$75,000 By marital status Married now Prior marriage Never married By children Any in house None in house By region Northeast North central South West
Type of skin cancert
Type of cancer
I
Other
I
Don'tknow~
34
21
3
42
39* 29c
23 18
3 4
35* 49 c
38* 11c
23 6
4 8
35* 75 c
16" 37b 39 a 36a
11 16 29 29
2 5 2 4
72* 42c 30c 31 °
16" 23 36b 52c
16 16 24 24
5 3 4 4
63* 58 36 c 20~
18" 30a 49 c 41 a
16 23 18 27
6 5 2 1
60* 43 a 31 c 31 b
38* 30 29
23 22 14
3 3 5
36* 45 52
29* 36a
17 22
3 4
51" 38 a
32* 32 31 32
19 23 20 20
4 2 5 3
45* 43 43 46
a, 0.01 < p < 0.05; b, 0.001 < p <0.01; c, p < 0.001. *Reference category. Differences tested using logistic regression to control for other variables (see text for model). tTest of difference in knowing melanoma is a skin cancer among participants in defined category in comparison with reference category. STest of difference in saying "don't know" what melanoma is among participants in defined category in comparison with reference category.
adults, those with m o r e education, those with higher incomes, and those without children living in the household. W h e n the knowledge measures were examined together a m o n g white participants at least 25 years of age, 21% were both unaware of m e l a n o m a and did not identify specific early signs of the cancer; of these people, 65% were male, 60% had annual incomes below $40,000, 67% had no m o r e than a high school education, and 35% had children riving in the household.
Variations in self-examination for skin cancer according to sociodemographic factors and knowledge of melanoma As with the knowledge measures, SSE was reported m o r e often b y w o m e n and white persons, and it increased steeply with age (Table V). A m o n g white participants at least 25 years o f age, 61% of w o m e n and 4 4 % o f m e n report SSE. It also was slightly m o r e c o m m o n a m o n g those with some education b e y o n d high school, but it varied little with
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income and area of residence. SSE was reported less often among respondents who were never married and those who had children in their household. Reported SSE was examined according to responses to the melanoma awareness and knowledge questions (Table V). With few exceptions, increased awareness and knowledge were related significantly with SSE. For example, the practice was reported by only 27% of those with no awareness of melanoma compared with 65% of those who knew it to be a kind of skin cancer. The practice also was reported infrequently among those who knew none of the early signs (24%) or the body sites (24%) for melanoma and was reported most often among those with knowledge of specific early signs (new mole or change in a mole) (67%) or of its occurrence on less exposed sites (back, chest, stomach) (65%). The practice also was more common among those with any knowledge of melanoma risk factors, but it varied little according to which risk factors were known (12% vs 49% to 56%). In further analyses (not shown), we found that melanoma knowledge and practices did not vary according to source of information on self-examination (see Table ffl). Learning from a dermatologist or other doctor, as opposed to other sources, was not related significantly with frequency of serf-examinations, awareness of melanoma, knowledge of early signs, knowledge of where melanoma occurs, or knowledge of risk factors. DISCUSSION
An important and unique characteristic of skin cancer is that the primary lesion is usually visible, even at an early stage. In most cases, people can discover their own lesions and seek early treatment. At a recent National Conference to Develop a Skin Cancer Agenda cosponsored by the AAD and the Centers for Disease Control and Prevention (CDC), an expert panel recommended SSE as "an inexpensive, noninvasive, easy-to-learn method of prescreening one's skin for suspect lesions that could benefit overall awareness of skin cancer and cutaneous health, complement other aspects of skin cancer detection, a n d . . , prevent complications associated with advanced disease." 16 This recommendation is especially applicable to melanoma because advanced cancer carries such a poor prognosis. 7 Although further research is needed to evaluate its effectiveness, 16 a recent report from a case-control study in Connecticut supports this recommendation; the authors found that those who practiced SSE had
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50% less advanced melanoma and significantly lower mortality from melanomaJ 7 In recent years, campaigns have been mounted to raise awareness of skin cancer and promote SSE in the general population. A prominent example is the national melanoma/skin cancer screening and educational program, sponsored by the AAD since 1985, which has provided educational infomaation to more than 50 million Americans and free annual skin cancer screenings to more than 750,000 AmericansjS, 19 Television and printed media campaigns to publicize the screening examinations have included some visually striking pictures of suspect moles and lesions, along with a message urging people to inspect their skin routinely for cancer. In 1995, the AAD launched a special campaign entitled ' 'Melanoma Self-examination Day Melanoma Monday: A Day for All Americans to Begin a Lifelong Habit of Examining their Skin." This nationally coordinated effort provided melanoma education to all Americans and promoted skin examinations, particularly inspection of pigmented lesions, beginning with the first Monday in May. Our analysis of the national public opinion survey conducted in advance of the Melanoma Self-examination Day campaign provides evidence justifying the effort and indicates that there are important bartiers to effective self-screening for early detection of melanoma. Further education is needed to alert almost half of adult Americans who are unaware of melanoma and the nearly 75% of the population who cannot accurately identify a specific sign of early melanoma. Although people are generally aware of skin cancer, they inadequately distingnish nonmelanoma (basal cell and squamous cell cancers) from melanoma skin cancer in terms of risk factors (high knowledge of sun-related factors, little knowledge of phenotypic factors), signs of early cancer, and body sites for cancer occurrence and skin examination. Public education efforts, such as those sponsored by the AAD over the past decade, probably have contributed to heightened awareness of skin cancer in general. ~8-2° Our survey results indicate, however, that future programs need to focus on increasing concern and knowledge of melanoma specifically. Our findings further suggest that lack of specific knowledge is an impediment to following recommended practices. More than 50% of Americans have never closely examined their skin for cancer, and most of those who have may be performing only partial examinations and may not be examining
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Table V. Self-examination for skin cancer according to sociodemographic factors and knowledge measures among the 1001 participants in the 1995 Melanoma Awareness and Ser-Examinafion Survey % Practicing % Practicing Sociodemographic factors
Overall By sex Female Male By race White Black By age (yr) 18-24 25-44 45-64 >-65 By education <12 yr High school graduate Some college College graduate By income <$20,000 $20,000-$39,999 $40,000-$74,999 >-$75,000 By marital status Married now Prior marriage Never married By children Any in house None in house By region Northeast North central South West
self-examination for signs of skin cancer or melanoma
46 52* 40c 49* 25a
21" 42b 62c 58c 42* 39 49a 54a
42* 48 46 53
Knowledge measures
Awareness of melanoma None As a type of cancer As a type of skin cancer Knowledge of early signs None Any New mole or change in mole Knowledge of site None Any On back, chest, stomach Knowledge of risk factors None Bad sunburns in childhood Fair skin Having lots of moles Being bom with moles Red hair and blue eyes Freckles Family history of melanoma History of stm exposure At least five of the eight factors
self-examination for signs of skin cancer or melanoma
27* 58~ 65c 24* 50~ 67c
24* 51c 65c 1U 54c 53c 54b 53b 56e 55c 49b 49b 56c
50* 54 28a 37* 50a 41" 45 48 49
*Reference category. Differences tested using logistic regression to control for other variables (see text for model). Test of difference in ever examining for skin cancer among participants in defined category in comparison with those in the reference category: a, 0.01
themselves accurately for early signs of melanoma. Furthermore, lack of awareness and knowledge was strongly associated with not practicing SSE and were the most c o m m o n reasons given by those who never examined their skin for not doing so. Most of the people who did examinetheir own skin for cancer had learned to do so from the news media and not from medical professionals. The relatively high
frequency of SSE reported by some o f our participants is curious. Although an optimal frequency of SSE has not been determined and probably needs to be set for each person on the basis of risk factors, weekly or even daffy examinations have not been widely recommended and are probably excessive.8, 9, 16 These reported behaviors further indicate the need for improved pubfic and professional edu-
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cation specifically focused on early detection of melanoma. The youngest adults in our survey, 15 to 24 years of age, had the lowest indicators of melanoma knowledge and lowest rates of SSE. The merits of promoting such practices at an early age are a matter of some debate. Melanoma incidence rates do not begin to increase sharply until about 40 years of age, although it is the most commonly diagnosed cancer among young women 25 to 29 years of age) Dysplastic or atypical moles, which may be precursors of melanoma, begin to appear and can change in size, shape, and color in high-risk younger adults. 6, 7 In addition, there is mounting evidence that the critical period of sun exposure that increases subsequent risk of melanoma occurs during youth. 21,22 Encouraging adolescents and yotmg adults to practice SSE along with avoidance of dangerous sun exposure may be the best ways to instill life-long health habits and foster early detection of melanoma in furore years. In this regard, it disturbs us to find that adults with children in their household had consistently less awareness and knowledge of melanoma and less often reported SSE. This finding shows the appropriateness of recent recommendations by the CDC and other agencies ~6 to give high priority to skin cancer prevention directed at parents and other caregivers of children and adolescents. Gender and socioeconomic status were found to be important correlates of melanoma knowledge and prevention practices. Men reported consistently lower measures of melanoma knowledge and SSE. This finding confirms reports from other studies on gender differences in knowledge and practices in preventive health2°, 23 and suggests an explanation for men's propensity to higher mortality from melanoma. 7,24 Persons with little education or low income also had less knowledge of melanoma and this is consistent with recent findings from ecologic studies suggesting poor survival and more frequent late-stage melanoma among those of lowest socioeconomic StatuS. 25 This survey provides the first nationally representative estimate of the prevalence of SSE in the United States. Similar rates of self-screening were reported from community studies in A u s t r a l i a26,27 and the United States. 28 These studies also reported lower prevalences of SSE in men and in persons of lower educational status. This study has limitations. Self-reported mea-
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sures of SSE practices may have been overstated or otherwise biased. Aside from age and race, we lacked information on participants' risk of melanoma, such as skin type, family history of melanoma, or overall self-assessment of risk, which is a potentially useful summary measure of tree risk. 2° Certainly it is most important for those at higher risk to be well informed and practice SSE. In this context, there is less urgency for knowledge of melanoma and practice of SSE among those with darker skin pigmentation because they are at considerably lower risk of melanoma. Perhaps the most critical population subgroup for targeting melanoma education consists of older white Americans with melanoma risk factors (such as family history, very fair skin, or many moles). It should be noted, however, that all population groups are at some risk, and all adults could benefit from the basic elements of public education. In conclusion, our findings of deficiencies in melanoma knowledge and practices related to early detection support recommendations for improved public and professional education programs focused on early detection of melanoma, a, 16,29 The message must clearly state the risks of melanoma and include information on the urgency of early detection, specific signs of early disease, the importance of complete body examinations, and simple appropriate action steps to take if warning signs are present. Furthermore, public and professional programs need to include effective outreach and tailor their messages with development of age- and literacy-appropriate materials and methods to reach audiences of lower education and income. In addition, efforts should go beyond deficits of knowledge and address issues of access to care and behavioral factors that may motivate at-risk persons to initiate SSE and seek examination by a trained professional. REFERENCES 1. Weinstock MA, Boggars HA, Ashley M, et al. Non-melanoma skin cancer mortality: a population-based study. Arch Dermatol 1991:127:1194-7. 2. Parker SL, Tong T, Bolden S, et al. Cancer statistics, 1996. CA Cancer J Clin 1996;46:5-28. 3. Miller BA, Ries LAG, Hankey BF, et al, editors. Cancer statistics review: 1973 1989. National Institutes of Health Publication No. 92-2789. Bethesda, MD: National Cancer Institute, 1992. 4. Centers for Disease Control and Prevention. Deaths from melanoma United States, 1973 1992. MMWR 1995;44: 337-47. 5. Wagener DK. Patterns of melanoma deaths in the United States. In: Davis DL, Hoel D, editors. Trends in cancer
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mortality in industrial countries; vo1609. New York: New York Academy of Sciences, 1990:252-8. Koh HK. Cutaneous melanoma. N Engl J Med 1991;325: 171-82. Balch CM, Houghton AN, Milton GW, et al. Cutaneous melanoma. 2nd ed. Philadelphia: JB Lippincott, 1992. Friedman ILl, Rigel DS, Silverman MK, et al. Malignant melanoma in the 1990's: the continued importance of early detection and the role of physician examination and self-examination of the skin. CA Cancer J Clin 1991;41: 201-26. Koh HK, Miller DR, Geller AC, et al. The current status of melanoma early detection and screening. Dermatol Clin 1995;13:623-34. NIH Consensus Development Panel on Early Melanoma. Diagnosis and treatment of early melanoma. JAMA 1992; 268:1314-9. Annitage P, Berry G. Statistical methods in medical research. 2nd ed. Oxford: Blackwell Scientific Publications, 1987. Breslow NE, Day NE. Statistical methods in cancer research: analysis of case-control studies; vol 1. Lyon: IARC Scientific Publications (No. 32), 1980. SAS7 Language Reference; version 6. Cary, NC: SAS Institute, 1994. National Center for Health Statistics. Health, United States, 1994. Hyattsville, MD: Public Health Service, 1995. Koh HK, Miller DR, Geller AC, et al. Skin cancer prevention and control. In: Greenwald P, Kramer BS, Weed DL, editors. The science and practice of cancer prevention and control. New York: Marcel-Dekker, 1995:611-40. Goldsmith L, Koh HK, Bewerse BA, et al. Proceedings from the conference to develop a national skin cancer agenda. American Academy of Dermatology and Centers for Disease Control and Prevention, April 8-10, 1995. Berwick M, Begg C, Fine JA, et al. Screening for cutaneous melanoma by skin self-examination. J Nat Cancer Inst 1996;88:17-23. Koh HK, Geller AC, Miller DR, et al. The early detection of and screening for melanoma: international status. Cancer 1995;75:674-83.
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19. Summary and analysis of the American Academy of Dermatology National Skin Cancer Screening Database with recommendations for public and professional awareness and education. Division of Cancer Prevention and Disease Control, Centers for Disease Control and Prevention, 1994. 20. Miller DR, Koh HK, Geller AC, et al. National survey of skin cancer awareness and prevention practices in older Americans. Am J Prey Med (in press) 21. Koh HK, Kligler BE, Lew RA. Sunlight and melanoma: evidence for and against causation. Photochem Photobiol 1990;51:765-79. 22. Weinstock MA, Colditz GA, Willett WC, et al. Nonfamilial cutaneous melanoma incidence in women associated with sun exposure before 20 years of age. Pediatrics 1989; 84:199-204. 23. Koh HK, Bak SM, Geller AC, et al. Sunbathinghabits and sunblockuse in 2459 Caucasian adults: results of a national survey. Am J Public Health (in press) 24. Geller AC, Koh HK, Miller DR, et al. Rising mortafity rates of malignant melanoma among men in the United States, 1973 1987. MMWR 1992;41:20-7. 25. Geller AC, Miller DR, Koh HK, et al. Malignant melanoma: another cancer disproportionately affecting the socioeconomically disadvantaged. Am J Pub Health (in press) 26. Theobald T, Marks R, Hill D. "Goodbye Sunshine": effects of a TV program about melanoma on beliefs, behaviour, and melanoma thickness. J Am Acad Dermatol 1991;25:717-23. 27. Girgis A, Campbell EM, Redman S, et al. Screening for melanoma: a community survey of prevalence and predictors. Med J Aust 1991;154:338-43. 28. Friedman LC, Bruce S, Webb JA, et al. Skin serf-examination in a population at increased risk for skin cancer. Am J Prey Med 1993;9:359-64. 29. Rhodes AR. Public education and cancer of the skin: What do people need to know about melanoma and nonmelanoma skin cancer? Cancer 1995;75:613-36.
Philadelphia, Pennsylvania; Dallas, Texas; New York, New York; and Schaumburg, Illinois Background: Skin cancers are common and there has been a dramatic increase in their incidence, particularly melanoma. However, little is known about awareness of melanoma and early detection practices in the general U.S. population. Objective: In 1995, the American Academy of Dermatology increased their efforts to promote awareness of melanoma. This study was conducted to document current knowledge of melanoma and self-examination practices. Methods: In February 1995, a telephone survey was conducted in a nationally representative sample of 1001 persons at least 18 years of age (3% margin of error) that included questions on knowledge, attitudes, and practices regarding early detection of melanoma. Results: Almost 42% of those surveyed were unaware of melanoma, and only 26% of those who were aware could identify its specific signs. Most recognized at least one common risk factor for melanoma (e.g., sun exposure, fair skin). However, many did not distinguish melanoma from other skin cancers in terms of risk factors, signs of early disease, and body site distribution. The lowest measures of melanoma knowledge and attitudes were found among those who are male, nonwhite, and parents, and those with the lowest level of education and income. More than half (54%) did not conduct a self-examination. This practice was most frequently reported by women, white persons, and the elderly, as well as those with a greater knowledge of melanoma. Conclusion: Ourresearch documents deficiencies in knowledge and practices related to early detection of melanoma in the general U.S. population and supports the need for public education about melanoma. (J Am Acad Dermatol 1996;34:962-70.)
Skin cancer, the most common form of cancer in the United States, will be newly diagnosed in more than one million Americans during 1996.1 MelaFrom the Departments of Dermatology and Medicine and the Cancer Prevention and Control Center, Boston University School of Medicinea; Boston University School of Public Healthb; Health Research Associates, NewtonC; Centers for Disease Control and Prevention, Division of Cancer Prevention and Control, Atlantaa; Department of Dermatology, University of Pennsylvania, Philadelphiae; Department of Dermatology, University of Texas, Dallasf; Department of Dermatology, New York University, New Yorkg; and American Academy of Dermatology, Schaurnburg. h Accepted for publication Feb. 5, 1996. Reprint requests: Donald R. Miller, Health Research Associates, 128 Chestnut St., Newton, MA 02165-2539. Copyright i996 by the American Academy of Dermatology, Inc. 0190-9622/96 $5.00 + 0
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noma represents only 3% to 4% of these diagnoses, but it accounts for the greatest number of deaths from skin cancer. In 1995, more than 7000 Americans died of this cancer and more than 38,000 received a new diagnosis of melanoma. 2-4 Furthermore, melanoma incidence and mortality have increased dramatically over the past two decades with rates of increase ranked among the highest of all cancers. 35 Early, thin melanoma lesions can usually be seen by patients, and surgical excision of these lesions almost always leads to cure without further treatment.6, 7 Hence, in theory, increasing public awareness and promoting early detection and treatment should help many people to have melanoma discovered and removed at an earlier stage and thereby re-
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duce mortality from melanoma. 8' 9 Skin self-examination (SSE) for cancer could enhance early detection of melanoma, and many organizations, including the American Academy of Dernmtology (AAD), advocate the practice of SSE and provide educational materials with pictorial instructions to foster and instruct in the examination. 9' 10 Little is known, however, about who practices SSE and what the public knows about SSE and melanoma prevention and early detection. Melanoma/Skin Cancer Detection and Prevention Mouth is an annual campaign by the AAD to increase awareness of melanoma and other skin cancers and to promote their early detection. In 1995, the AAD added a special program to promote "Melanoma Self-examination D a y " ("Melanoma Monday") and to raise public awareness of melanoma, encourage physician visits for examination of pigmented lesions, and promote SSE. Shortly before the publicity for this program began, a national survey was conducted to document current knowledge of melanoma and self-examination practices. The results of that survey are presented in this report. METHODS The First Melanoma Awareness and Skin Examination survey was conducted in February 1995 by the Opinion Research Corporation (Princeton, N.J.), in collaboration with the AAD and Public Communications Inc. (PCI). The telephone survey was conducted among a national probability sample of 1001 adults, 18 years of age and older, riving in private households in the United States. The final sample consisted of 1001 respondents, providing an overall margin of error of 3.0%. The survey included 10 questions on familiarity with the term melanoma, early signs of melanoma, self-examination practices (including reasons for not examining the skin and examination frequency), warning signs and factors associated with increased risk of the development of melanoma, and most common body sites of melanoma. In addition, information was obtained on nine demographic and socioeconomic variables (sex, age, race/ethnicity, education, income, marital status, children in household, and state of residence). The frequency distributions of survey responses for each of the questions on melanoma knowledge and practice of SSE were examined overall and with stratification according to the demographic and socioeconomic variables. Initially, differences in response frequencies between groups were evaluated with chi-square tests) 1 Subsequently, multivariate analysis was conducted by means of logistic regression to adjust for all of the demo-
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graphic and socioeconomic variables simultaneously. 12 All test results presented in this report come from logistic regression analysis with a specific category of response to a knowledge or practice question as the dependent variable and dichotomous terms (dummy variables) for the demographic and socioeconomic variables; all models included terms for sex (male, female), age (<25 years, 25 to 44 years, 45 to 64 years, 65 years and older), race/ethnicity (white, other), education (<12 years, high school graduate, some college or technical school, advanced degree), annual household income (<$20,000, $20,000$39,999, $40,000-$74,999, $75,000 and higher), marital status (never married, currently married, prior marriage [divorced, separated, or widowed]), children younger than 18 years old in the household (yes/no), and area of residence (northeast, north central, south, west). All analyses were conducted with statistical software from the SAS Institute (Cary, N.C.) 13 RESULTS Demographic and socioeconomic characteristics of the 1001 participants in the survey (Table I) are comparable to measures for the general U.S. adult population from the census and other national surveys. 14 Participants resided in 43 states evenly distributed throughout the country. The sample consisted of nearly equal numbers of men and women, two thirds of respondents were between 25 and 65 years of age, and most (90%) had at least a high school education. Almost 81% of respondents were non-Hispanic Caucasians. M e l a n o m a awareness and k n o w l e d g e Table II presents responses to survey questions on melanoma awareness and knowledge. When asked: "Can you tell me what melanoma is?", nearly 42% of respondents were unaware of the term, 55% knew it to be a type of cancer, and 34% specifically knew it to be a type of skin cancer. When participants were read a list of melanoma risk factors, most (95%) recognized at least one as something that "can increase risk of melanoma." Affirmative responses were particularly frequent for sun-related risk factors (82.3% for history of sun exposure and 58.4% for bad sunburns in childhood), and relatively infrequent for moles (41.3% for having many moles and 28.1% for being born with moles) and for two of the three skin sensitivity (phenotype) questions (63.3% for fair skin, 27.8% for red hair and blue eyes, and 21.7% for freckles). When asked to name the early signs of melanoma, 37% said that they did not know, and only 26% correctly identified specific signs of
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Table I. Characteristics of the 1001 participants
Table II. Awareness and knowledge of
in the 1995 M d a n o m a Awareness and Self-Examination Survey
melanoma among the 1001 participants in the 1995 Melanoma Awareness and Self-Examination Survey
Variable Sex Female Male Race/Ethnicity White, non-Hispanic Black, non-Hispanic Hispanic Other Age (yr) <25 25-44 45-64 ->65 Area of residence Northeast North Central South West Education >12 High school graduate Some college or technical school Advanced degrees Unknown Annual household income <$20,000 $20,000-$39,999 $40,000-$74,999 ->$75,000 Unknown Martial status Currently married Divorced, separated, widowed Never married Children in household Yes No
{
%
Can you tell me what melanoma is ?
51.3 48.7 80.9 11.1 7.0 1.0 14.7 42.7 25.5 17.1 21.0 22.4 35.7 20.9 9.4 34.5 25.8 29.4 0.9 18.4 31.3 22.7 8.6 19.0 57.3 21.9 20.8 31.4 68.6
Some kind of skin cancer 34.1% Some kind of cancer 20.5% Other 3.7% Don't know 41.7% Which of the following do you believe can increase risk of melanoma?* History of sun exposure 82.3% Bad sunburns in childhood 58.4% Having lots of moles 41.3% Being born with moles 28.1% Fair skin 63.3% Red hair and blue eyes 27.8% Freckles 21.7% Family history of melanoma 67.4% Other 0.5% None of these, don't know 5.0% Can you name early signs of melanoma? A change in a mole 21.8% A new mole 4.5% A sore that won't heal 5.1% A lump 2.2% Any type of change in the skin 4.4% Blotchy skin or dark spots 15.0% Redness 2.0% Discoloration 3.9% Skin rash 2.2% Dry, itchy, or scaly skin 0.8% Other 1.3% Don't know 36.7% Where is melanoma most likely to occur?* Head and shoulders 51.7% Arms and legs 35.5% Chest and stomach 5.4% Back 10.3% Anywhere exposed to the sun 12.3% Don't know 17.7% *Response categoriesare not mutuallyexclusive;respondentsmay choosemorethanone.
early melanoma (a change in a mole or a new mole); most of the other responses were not specific for melanoma (e.g., blotchy skin).6 When asked where on the body they thought melanoma was most likely to occur, most reported head and shoulders, arms and legs, or "sun-exposed areas," more suggestive of nonmelanoma skin cancer. 15 Only 15% included body areas such as the back, chest, and stomach, which are often covered and may be more difficult to examine.7
Skin self-examination practices Responses to SSE questions are shown in Table HI. When asked "Do you ever closely examine
yourself for signs of skin cancer or melanoma?", 46% reported that they did, and most of them (85%) said that they examined their skin at least monthly. However, only 26% reported looking specifically for changes in moles or new moles; most said that they looked for any changes in the skin or its pigmentation. Only 29% of self-examiners said that they learned to examine their skin from medical professionals and only 8% learned from a dermatologist. The most frequent source of knowledge about SSE was the news media, and 16% learned from a friend or relative. We also asked those who exam-
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Table III. Self-examination for skin cancer among the 1001 participants in the 1995 Melanoma Awareness and Self-Examination Survey Do you ever closely examine yourself for signs of skin cancer or melanoma?
Yes* (45.9%; n = 479) How often do you examine your skin? Once a year at most Every 2 to 6 months Once a month Weekly Daily What do you look for on your skin? Things that weren't there before Changes in moles New moles Color or pigment changes Sore that won't heal Bumps and lumps Dry, itchy, or scaly skin Redness Skin rash Blotchy skin or dark spots Other
4.9% 10.6% 22.4% 24.5% 37.6% 34.2% 21.7% 4.1% 16.2% 4.5% 6.8% 3.3% 0.8% 1.1% 2.9% 3.4%
No* (53.5%; n = 518) Why don't you examine your skin? Never think about it Didn't know I should Didn't know what to look for Wouldn't know what to do Would notice, don't need to Unlikely to get melanoma Not in sun enough Have enough to worry about Don't have time Don't see well enough Frightened to find something Other Don't know
22.7% 14.0% 11.2% 0.7% 9.9% 8.0% 4.4% 2.2% 2.6% 0.6% 0.7% 9.7% 13.4%
Where did you leam that you shouM examine your skin for cancer?
Dermatologist Doctor Health services School
7.7% 18.8% 3.1% 8.8%
News media Family member or friend Other Don't know
28.1% 15.7% 11.7% 6.0%
*Four respondents (0.5%) did not answer the question.
ined their skin what they would do if they noticed what they thought might be melanoma; 91% said that they would promptly call or see their doctor (14.8% said they would contact a dermatologist, 76.7% said they would contact another type of doctor); only 2% said that they would not act promptly (0.8% would tell their doctor at their next medical visit, 1.3% would wait to see if it goes away or changes). The remaining 54% of respondents (n = 518) who never examined their skin for cancer were asked why they did not. The responses were approximately equally distributed into four groups: (1) low awareness ("never think about it"); (2) little knowledge ("did not know that I should," "did not know what to look for," "did not know what to do if something were found"); (3) denial of risk ("did not need to," "unlikely to get melanoma," "not in sun enough"); and (4) other ("had enough to worry about," "don't see well enough," "don't have enough time," "frightened to find something"), including simply not knowing why they did not examine themselves.
Variations in knowledge according to sociodemographic factors Melanoma awareness varied substantially by several of the factors (Table IV). Knowing the term at all a n d knowing that it is a kind of skin cancer were both substantially more common among women, white persons, and adults older than 25 years of age, although there was little variation in knowledge among the three age groups above 25 years. Awareness also increased progressively with increasing education and with increasing annual income up to a level of $40,000 per year. Apparent variation in melanoma awareness by marital status was not statistically significant after adjustment for age and other factors, but adults with children living in their households had less awareness of melanoma. Variation in melanoma awareness by area of residence was modest and not statistically significant. Other measures of melanoma knowledge, including knowledge of risk factors and early signs, tended to follow similar patterns with higher levels of knowledge among women, white persons, older
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Table I V . Awareness of m e l a n o m a according to sociodemographic factors a m o n g the 1001 participants in the 1995 M e l a n o m a Awareness and Self-examination Survey Can you tell me what melanoma is? (%)
Overall By sex Female Male By race White Black By age (yr) 18-24 25-44 45-64 ->65 By education <12 yr High school graduate Some college College graduate By income <$20,000 $20,000-$39,999 $40,000-$74,999 ->$75,000 By marital status Married now Prior marriage Never married By children Any in house None in house By region Northeast North central South West
Type of skin cancert
Type of cancer
I
Other
I
Don'tknow~
34
21
3
42
39* 29c
23 18
3 4
35* 49 c
38* 11c
23 6
4 8
35* 75 c
16" 37b 39 a 36a
11 16 29 29
2 5 2 4
72* 42c 30c 31 °
16" 23 36b 52c
16 16 24 24
5 3 4 4
63* 58 36 c 20~
18" 30a 49 c 41 a
16 23 18 27
6 5 2 1
60* 43 a 31 c 31 b
38* 30 29
23 22 14
3 3 5
36* 45 52
29* 36a
17 22
3 4
51" 38 a
32* 32 31 32
19 23 20 20
4 2 5 3
45* 43 43 46
a, 0.01 < p < 0.05; b, 0.001 < p <0.01; c, p < 0.001. *Reference category. Differences tested using logistic regression to control for other variables (see text for model). tTest of difference in knowing melanoma is a skin cancer among participants in defined category in comparison with reference category. STest of difference in saying "don't know" what melanoma is among participants in defined category in comparison with reference category.
adults, those with m o r e education, those with higher incomes, and those without children living in the household. W h e n the knowledge measures were examined together a m o n g white participants at least 25 years of age, 21% were both unaware of m e l a n o m a and did not identify specific early signs of the cancer; of these people, 65% were male, 60% had annual incomes below $40,000, 67% had no m o r e than a high school education, and 35% had children riving in the household.
Variations in self-examination for skin cancer according to sociodemographic factors and knowledge of melanoma As with the knowledge measures, SSE was reported m o r e often b y w o m e n and white persons, and it increased steeply with age (Table V). A m o n g white participants at least 25 years o f age, 61% of w o m e n and 4 4 % o f m e n report SSE. It also was slightly m o r e c o m m o n a m o n g those with some education b e y o n d high school, but it varied little with
Journal of the American Academy of Dermatology Volume 34, Number 6
income and area of residence. SSE was reported less often among respondents who were never married and those who had children in their household. Reported SSE was examined according to responses to the melanoma awareness and knowledge questions (Table V). With few exceptions, increased awareness and knowledge were related significantly with SSE. For example, the practice was reported by only 27% of those with no awareness of melanoma compared with 65% of those who knew it to be a kind of skin cancer. The practice also was reported infrequently among those who knew none of the early signs (24%) or the body sites (24%) for melanoma and was reported most often among those with knowledge of specific early signs (new mole or change in a mole) (67%) or of its occurrence on less exposed sites (back, chest, stomach) (65%). The practice also was more common among those with any knowledge of melanoma risk factors, but it varied little according to which risk factors were known (12% vs 49% to 56%). In further analyses (not shown), we found that melanoma knowledge and practices did not vary according to source of information on self-examination (see Table ffl). Learning from a dermatologist or other doctor, as opposed to other sources, was not related significantly with frequency of serf-examinations, awareness of melanoma, knowledge of early signs, knowledge of where melanoma occurs, or knowledge of risk factors. DISCUSSION
An important and unique characteristic of skin cancer is that the primary lesion is usually visible, even at an early stage. In most cases, people can discover their own lesions and seek early treatment. At a recent National Conference to Develop a Skin Cancer Agenda cosponsored by the AAD and the Centers for Disease Control and Prevention (CDC), an expert panel recommended SSE as "an inexpensive, noninvasive, easy-to-learn method of prescreening one's skin for suspect lesions that could benefit overall awareness of skin cancer and cutaneous health, complement other aspects of skin cancer detection, a n d . . , prevent complications associated with advanced disease." 16 This recommendation is especially applicable to melanoma because advanced cancer carries such a poor prognosis. 7 Although further research is needed to evaluate its effectiveness, 16 a recent report from a case-control study in Connecticut supports this recommendation; the authors found that those who practiced SSE had
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50% less advanced melanoma and significantly lower mortality from melanomaJ 7 In recent years, campaigns have been mounted to raise awareness of skin cancer and promote SSE in the general population. A prominent example is the national melanoma/skin cancer screening and educational program, sponsored by the AAD since 1985, which has provided educational infomaation to more than 50 million Americans and free annual skin cancer screenings to more than 750,000 AmericansjS, 19 Television and printed media campaigns to publicize the screening examinations have included some visually striking pictures of suspect moles and lesions, along with a message urging people to inspect their skin routinely for cancer. In 1995, the AAD launched a special campaign entitled ' 'Melanoma Self-examination Day Melanoma Monday: A Day for All Americans to Begin a Lifelong Habit of Examining their Skin." This nationally coordinated effort provided melanoma education to all Americans and promoted skin examinations, particularly inspection of pigmented lesions, beginning with the first Monday in May. Our analysis of the national public opinion survey conducted in advance of the Melanoma Self-examination Day campaign provides evidence justifying the effort and indicates that there are important bartiers to effective self-screening for early detection of melanoma. Further education is needed to alert almost half of adult Americans who are unaware of melanoma and the nearly 75% of the population who cannot accurately identify a specific sign of early melanoma. Although people are generally aware of skin cancer, they inadequately distingnish nonmelanoma (basal cell and squamous cell cancers) from melanoma skin cancer in terms of risk factors (high knowledge of sun-related factors, little knowledge of phenotypic factors), signs of early cancer, and body sites for cancer occurrence and skin examination. Public education efforts, such as those sponsored by the AAD over the past decade, probably have contributed to heightened awareness of skin cancer in general. ~8-2° Our survey results indicate, however, that future programs need to focus on increasing concern and knowledge of melanoma specifically. Our findings further suggest that lack of specific knowledge is an impediment to following recommended practices. More than 50% of Americans have never closely examined their skin for cancer, and most of those who have may be performing only partial examinations and may not be examining
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Table V. Self-examination for skin cancer according to sociodemographic factors and knowledge measures among the 1001 participants in the 1995 Melanoma Awareness and Ser-Examinafion Survey % Practicing % Practicing Sociodemographic factors
Overall By sex Female Male By race White Black By age (yr) 18-24 25-44 45-64 >-65 By education <12 yr High school graduate Some college College graduate By income <$20,000 $20,000-$39,999 $40,000-$74,999 >-$75,000 By marital status Married now Prior marriage Never married By children Any in house None in house By region Northeast North central South West
self-examination for signs of skin cancer or melanoma
46 52* 40c 49* 25a
21" 42b 62c 58c 42* 39 49a 54a
42* 48 46 53
Knowledge measures
Awareness of melanoma None As a type of cancer As a type of skin cancer Knowledge of early signs None Any New mole or change in mole Knowledge of site None Any On back, chest, stomach Knowledge of risk factors None Bad sunburns in childhood Fair skin Having lots of moles Being bom with moles Red hair and blue eyes Freckles Family history of melanoma History of stm exposure At least five of the eight factors
self-examination for signs of skin cancer or melanoma
27* 58~ 65c 24* 50~ 67c
24* 51c 65c 1U 54c 53c 54b 53b 56e 55c 49b 49b 56c
50* 54 28a 37* 50a 41" 45 48 49
*Reference category. Differences tested using logistic regression to control for other variables (see text for model). Test of difference in ever examining for skin cancer among participants in defined category in comparison with those in the reference category: a, 0.01
themselves accurately for early signs of melanoma. Furthermore, lack of awareness and knowledge was strongly associated with not practicing SSE and were the most c o m m o n reasons given by those who never examined their skin for not doing so. Most of the people who did examinetheir own skin for cancer had learned to do so from the news media and not from medical professionals. The relatively high
frequency of SSE reported by some o f our participants is curious. Although an optimal frequency of SSE has not been determined and probably needs to be set for each person on the basis of risk factors, weekly or even daffy examinations have not been widely recommended and are probably excessive.8, 9, 16 These reported behaviors further indicate the need for improved pubfic and professional edu-
Journal of the American Academy of Dermatology Volume 34, Number 6
cation specifically focused on early detection of melanoma. The youngest adults in our survey, 15 to 24 years of age, had the lowest indicators of melanoma knowledge and lowest rates of SSE. The merits of promoting such practices at an early age are a matter of some debate. Melanoma incidence rates do not begin to increase sharply until about 40 years of age, although it is the most commonly diagnosed cancer among young women 25 to 29 years of age) Dysplastic or atypical moles, which may be precursors of melanoma, begin to appear and can change in size, shape, and color in high-risk younger adults. 6, 7 In addition, there is mounting evidence that the critical period of sun exposure that increases subsequent risk of melanoma occurs during youth. 21,22 Encouraging adolescents and yotmg adults to practice SSE along with avoidance of dangerous sun exposure may be the best ways to instill life-long health habits and foster early detection of melanoma in furore years. In this regard, it disturbs us to find that adults with children in their household had consistently less awareness and knowledge of melanoma and less often reported SSE. This finding shows the appropriateness of recent recommendations by the CDC and other agencies ~6 to give high priority to skin cancer prevention directed at parents and other caregivers of children and adolescents. Gender and socioeconomic status were found to be important correlates of melanoma knowledge and prevention practices. Men reported consistently lower measures of melanoma knowledge and SSE. This finding confirms reports from other studies on gender differences in knowledge and practices in preventive health2°, 23 and suggests an explanation for men's propensity to higher mortality from melanoma. 7,24 Persons with little education or low income also had less knowledge of melanoma and this is consistent with recent findings from ecologic studies suggesting poor survival and more frequent late-stage melanoma among those of lowest socioeconomic StatuS. 25 This survey provides the first nationally representative estimate of the prevalence of SSE in the United States. Similar rates of self-screening were reported from community studies in A u s t r a l i a26,27 and the United States. 28 These studies also reported lower prevalences of SSE in men and in persons of lower educational status. This study has limitations. Self-reported mea-
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sures of SSE practices may have been overstated or otherwise biased. Aside from age and race, we lacked information on participants' risk of melanoma, such as skin type, family history of melanoma, or overall self-assessment of risk, which is a potentially useful summary measure of tree risk. 2° Certainly it is most important for those at higher risk to be well informed and practice SSE. In this context, there is less urgency for knowledge of melanoma and practice of SSE among those with darker skin pigmentation because they are at considerably lower risk of melanoma. Perhaps the most critical population subgroup for targeting melanoma education consists of older white Americans with melanoma risk factors (such as family history, very fair skin, or many moles). It should be noted, however, that all population groups are at some risk, and all adults could benefit from the basic elements of public education. In conclusion, our findings of deficiencies in melanoma knowledge and practices related to early detection support recommendations for improved public and professional education programs focused on early detection of melanoma, a, 16,29 The message must clearly state the risks of melanoma and include information on the urgency of early detection, specific signs of early disease, the importance of complete body examinations, and simple appropriate action steps to take if warning signs are present. Furthermore, public and professional programs need to include effective outreach and tailor their messages with development of age- and literacy-appropriate materials and methods to reach audiences of lower education and income. In addition, efforts should go beyond deficits of knowledge and address issues of access to care and behavioral factors that may motivate at-risk persons to initiate SSE and seek examination by a trained professional. REFERENCES 1. Weinstock MA, Boggars HA, Ashley M, et al. Non-melanoma skin cancer mortality: a population-based study. Arch Dermatol 1991:127:1194-7. 2. Parker SL, Tong T, Bolden S, et al. Cancer statistics, 1996. CA Cancer J Clin 1996;46:5-28. 3. Miller BA, Ries LAG, Hankey BF, et al, editors. Cancer statistics review: 1973 1989. National Institutes of Health Publication No. 92-2789. Bethesda, MD: National Cancer Institute, 1992. 4. Centers for Disease Control and Prevention. Deaths from melanoma United States, 1973 1992. MMWR 1995;44: 337-47. 5. Wagener DK. Patterns of melanoma deaths in the United States. In: Davis DL, Hoel D, editors. Trends in cancer
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