**2. Melanoma and non-melanoma incidence, mortality and risk factors**

Skin cancer is the most common cancer in the US, with almost three million individuals being diagnosed annually [1]. Both melanoma and non-melanoma (or keratinocyte) skin cancer (NMSC) incidence rates have been increasing in recent decades [2]-[4]. In 2012, melanoma is predicted to be the fifth most common cancer among US men and the sixth most common cancer among women [2]. Risk factors for melanoma and NMSC include male sex, age over 50 years, personal or family history of melanoma or NMSC, red hair, blue or green eyes, Fitzpatrick skin type I (very fair skin sensitive to ultraviolet radiation [UV]) with freckles, actinic keratosis on the head, familial atypical mole-melanoma syndrome, or numerous (i.e., > 100) moles [2], [5]-[15]. Additionally, many melanomas and NMSCs can be attributed to UV exposure such as via outdoor occupations, one blistering sunburn prior to age 18, multiple sunburns at any age, or indoor tanning [15]-[21].

© 2013 Heckman et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## **3. Efficacy of skin cancer screening**

During a total cutaneous examination (TCE), the healthcare professional uses observation by sight, sometimes augmented by serial photography and/or dermoscopy to detect not only skin cancer but also risk factors for skin cancer (e.g., actinic keratoses) [22]. Suspicious lesions may then be biopsied and examined histologically. TCE also allows the healthcare professional the opportunity to educate the patient regarding their risk of skin cancer [22]-[24]. Screening of those at high risk for skin cancer detects tumors at an earlier stage when tumors are thinner, resulting in lower mortality rates [25]-[31]. Due to their clinical training and expertise, dermatologists are able to detect melanoma tumors during an early stage of growth, whereas patients may not notice a tumor until it is noticeably thick [32]-[34]. To date there are no major randomized controlled trials assessing the efficacy of TCE, but a case-control study found that melanoma patients who had a TCE in the three years prior to their diagnosis were 14% less likely to have thick melanoma, resulting in 26% fewer deaths [25]. Specificity for detection of melanoma through TCE is comparable to that of other cancer screening tests [35]. Most professional organizations recommend total cutaneous examination (TCE) for high risk individuals [1], [36]-[38], and some recommend population screening [39]; although, in 2009 the US Preventive Services Task Force concluded that there was insufficient evidence to recommend skin cancer screening for the general adult population [40].

respectively [51], [54]. With the introduction of the Patient Protection and Affordable Care Act, those previously without health insurance will have access to medical care [56]. In addition,

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Although efficacious and cost-effective, rates of *ever* having had a TCE are low at approxi‐ mately 15-17% among US adults [58], [59]. Despite the recommendation from some organiza‐ tions for monthly SSE, SSE rates are also suboptimal. US and Australian studies conducted from 1991 to 2004 found that only 23-61% of individuals performed SSE at least annually [60]- [66]. A study of Scottish patients also noted that approximately one third of patients did not seek medical attention until more than three months after noticing a worrisome pigmented lesion, potentially contributing to thicker melanomas [67]. Due to the relatively low rates of skin cancer screening, it is important to identify efficacious and cost-effective interventions to increase engagement in screening behavior, particularly among high risk groups such as men

Several psychosocial variables have been found to be associated with skin cancer screening. Dermatologists' main reason for not conducting TCE is patients' perceived embarrassment or reluctance [68]. An Australian study found that having a TCE in the past three years was associated with having a positive attitude toward skin cancer screening [69]. TCE intentions were higher among first-degree relatives of melanoma patients reporting greater physician and family support and perceiving greater benefits (e.g., to prevent cancer) of and lesser barriers (e.g., not enough time, anxiety) to TCE [70]. Barriers to TCE reported by Australian employees included fear of being diagnosed and difficulty attending appointments during work hours [71]. SSE has been found to be associated with higher SSE self-efficacy (i.e., SSErelated confidence) [72] and perceived benefits of and barriers to SSE [73] among melanoma patients/survivors. Intentions to receive SSE were higher among individuals with higher family support and higher benefits and lower barriers to self-examination [70]. SSE-related benefits were the strongest predictor of SSE among individuals from families with familial atypical multiple mole melanoma [74]. Other barriers to self-detection include limited ability to recall the skin's appearance and undercounting the number of moles on the skin [75]. Physicians, family, and media may serve as cues to action in skin cancer prevention and

Community and mass media campaigns (e.g., SkinWatch) that have increased TCE have been conducted mostly in Australia [35], [77]. For example, SkinWatch, a three-year Australian rural and regional community-based randomized controlled trial, involved community education ("self-help guide" to skin examination and melanoma risk factors, available in physicians'

this law will increase the focus on prevention of chronic illnesses such as cancer [57].

50 years of age and older.

detection [76].

**5. Psychosocial barriers to skin cancer screening**

**6. Prior interventions to increase skin cancer screening**

Patients and their family/friends are the first to spot half to three quarters of all melanomas [41]-[45]. To perform SSE, individuals are instructed to carefully examine all of their skin for abnormal spots following the "ABCDE" criteria: asymmetry, irregular borders, variation in color, large diameter (i.e., >6mm or a pencil eraser), and evolving (i.e., a changing spot) [46]. Skin self-examination (SSE) is associated with thinner tumors [47], may shorten the time to diagnosis [48], and may reduce melanoma mortality by up to 63% [49]. Both the National Cancer Institute [38] and the American Cancer Society [36] recommend monthly SSE.

## **4. Cost-effectiveness and frequency of skin cancer screening**

Because of its high prevalence, NMSC is among the mostly costly cancers to treat among the Medicare population [50]. SSEs are cost-effective in that people can perform them on their own; however, there is the potential for otherwise unnecessary medical visits. Screening programs with cost ratios less than \$50K per year of life saved are said to be cost-effective [51]-[54]. Two studies found that dermatologist skin cancer screening for individuals 50 years of age or older is cost-effective with costs of \$10-\$16K per quality-adjusted life year [QALY] saved overall and \$35K per QALY for biennial screening of siblings of melanoma patients; whereas, annual screening of the general population is not cost-effective [52], [53]. A 1996 Australian study of the cost-effectiveness of every five-year screenings by family practice physicians of men over 50 years of age found a cost-effectiveness of \$6.9K per QALY [55]. In comparison, the costeffectiveness ratios for biennial mammography for women ages 50-69 years and for colorectal cancer screening every five years after age 50 are \$30.5K and \$47.4K per QALY saved, respectively [51], [54]. With the introduction of the Patient Protection and Affordable Care Act, those previously without health insurance will have access to medical care [56]. In addition, this law will increase the focus on prevention of chronic illnesses such as cancer [57].

Although efficacious and cost-effective, rates of *ever* having had a TCE are low at approxi‐ mately 15-17% among US adults [58], [59]. Despite the recommendation from some organiza‐ tions for monthly SSE, SSE rates are also suboptimal. US and Australian studies conducted from 1991 to 2004 found that only 23-61% of individuals performed SSE at least annually [60]- [66]. A study of Scottish patients also noted that approximately one third of patients did not seek medical attention until more than three months after noticing a worrisome pigmented lesion, potentially contributing to thicker melanomas [67]. Due to the relatively low rates of skin cancer screening, it is important to identify efficacious and cost-effective interventions to increase engagement in screening behavior, particularly among high risk groups such as men 50 years of age and older.

## **5. Psychosocial barriers to skin cancer screening**

**3. Efficacy of skin cancer screening**

250 Highlights in Skin Cancer

During a total cutaneous examination (TCE), the healthcare professional uses observation by sight, sometimes augmented by serial photography and/or dermoscopy to detect not only skin cancer but also risk factors for skin cancer (e.g., actinic keratoses) [22]. Suspicious lesions may then be biopsied and examined histologically. TCE also allows the healthcare professional the opportunity to educate the patient regarding their risk of skin cancer [22]-[24]. Screening of those at high risk for skin cancer detects tumors at an earlier stage when tumors are thinner, resulting in lower mortality rates [25]-[31]. Due to their clinical training and expertise, dermatologists are able to detect melanoma tumors during an early stage of growth, whereas patients may not notice a tumor until it is noticeably thick [32]-[34]. To date there are no major randomized controlled trials assessing the efficacy of TCE, but a case-control study found that melanoma patients who had a TCE in the three years prior to their diagnosis were 14% less likely to have thick melanoma, resulting in 26% fewer deaths [25]. Specificity for detection of melanoma through TCE is comparable to that of other cancer screening tests [35]. Most professional organizations recommend total cutaneous examination (TCE) for high risk individuals [1], [36]-[38], and some recommend population screening [39]; although, in 2009 the US Preventive Services Task Force concluded that there was insufficient evidence to

Patients and their family/friends are the first to spot half to three quarters of all melanomas [41]-[45]. To perform SSE, individuals are instructed to carefully examine all of their skin for abnormal spots following the "ABCDE" criteria: asymmetry, irregular borders, variation in color, large diameter (i.e., >6mm or a pencil eraser), and evolving (i.e., a changing spot) [46]. Skin self-examination (SSE) is associated with thinner tumors [47], may shorten the time to diagnosis [48], and may reduce melanoma mortality by up to 63% [49]. Both the National

Because of its high prevalence, NMSC is among the mostly costly cancers to treat among the Medicare population [50]. SSEs are cost-effective in that people can perform them on their own; however, there is the potential for otherwise unnecessary medical visits. Screening programs with cost ratios less than \$50K per year of life saved are said to be cost-effective [51]-[54]. Two studies found that dermatologist skin cancer screening for individuals 50 years of age or older is cost-effective with costs of \$10-\$16K per quality-adjusted life year [QALY] saved overall and \$35K per QALY for biennial screening of siblings of melanoma patients; whereas, annual screening of the general population is not cost-effective [52], [53]. A 1996 Australian study of the cost-effectiveness of every five-year screenings by family practice physicians of men over 50 years of age found a cost-effectiveness of \$6.9K per QALY [55]. In comparison, the costeffectiveness ratios for biennial mammography for women ages 50-69 years and for colorectal cancer screening every five years after age 50 are \$30.5K and \$47.4K per QALY saved,

Cancer Institute [38] and the American Cancer Society [36] recommend monthly SSE.

**4. Cost-effectiveness and frequency of skin cancer screening**

recommend skin cancer screening for the general adult population [40].

Several psychosocial variables have been found to be associated with skin cancer screening. Dermatologists' main reason for not conducting TCE is patients' perceived embarrassment or reluctance [68]. An Australian study found that having a TCE in the past three years was associated with having a positive attitude toward skin cancer screening [69]. TCE intentions were higher among first-degree relatives of melanoma patients reporting greater physician and family support and perceiving greater benefits (e.g., to prevent cancer) of and lesser barriers (e.g., not enough time, anxiety) to TCE [70]. Barriers to TCE reported by Australian employees included fear of being diagnosed and difficulty attending appointments during work hours [71]. SSE has been found to be associated with higher SSE self-efficacy (i.e., SSErelated confidence) [72] and perceived benefits of and barriers to SSE [73] among melanoma patients/survivors. Intentions to receive SSE were higher among individuals with higher family support and higher benefits and lower barriers to self-examination [70]. SSE-related benefits were the strongest predictor of SSE among individuals from families with familial atypical multiple mole melanoma [74]. Other barriers to self-detection include limited ability to recall the skin's appearance and undercounting the number of moles on the skin [75]. Physicians, family, and media may serve as cues to action in skin cancer prevention and detection [76].

### **6. Prior interventions to increase skin cancer screening**

Community and mass media campaigns (e.g., SkinWatch) that have increased TCE have been conducted mostly in Australia [35], [77]. For example, SkinWatch, a three-year Australian rural and regional community-based randomized controlled trial, involved community education ("self-help guide" to skin examination and melanoma risk factors, available in physicians' waiting rooms), a media campaign (press regarding the program and advertisements), and volunteer recruitment and activities (training of a "Volunteer SkinWatch Coordinator" in each community to serve as liaison between the community and research team). More than 16,000 people attended SkinWatch screening clinics conducted by general practitioners and special screening services [78], [79]. By two years, screening rates almost tripled in intervention communities [35]. Screening attendance was associated with age 40-49 years, fair skin, personal history of skin cancer, concern about a spot or mole, and not having had a recent TCE [80]. Reasons endorsed for failing to attend screening services included a lack of knowledge regarding services, not having time to attend services, and having had a TCE recently [80]. A few studies assessing interventions to increase TCE have found low (2-19%) uptake rates even among high risk populations [28], [81]. On the other hand, a more recent Australian study found that 71% of employees attended a free workplace skin cancer screening [71]. Finally, Manne and colleagues [82] found that a tailored print intervention increased TCE intentions and performance among first degree relatives of melanoma patients.

Health interventions targeted specifically to men may benefit from a consideration of mascu‐ linity [109]-[117]. For example, one study found that more masculine college students were more likely to intend to do SSE if they received a worry control versus a response-efficacy (i.e., screening can detect skin cancer when it's most treatable) message [115]. Studies have found barriers to healthcare utilization and prevention among men that may be related to a stereo‐ typical masculine identity including discomfort with communication, feelings of vulnerability or invincibility, and even homophobia [111]. Thus, interventions for men should emphasize "masculine norms" such as self-reliance, emotional control, and power [109]. A few European and Australian interventions targeting middle-aged and older men included male celebrity modeling, use of photos, a website, free exams, and education and were successful in increas‐ ing SSE [114], [118], [119] and TCE [120]-[122]. Geller and colleagues (2006) also recommend a national survey to assess men for risk factors, perceived susceptibility, attitudes toward TCE

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**Figure 1.** Adjusted predicted value (%) for having total-body skin examination among US adults, National Health In‐

and SSE, perceived barriers, and potential social supports [113].

Adapted from [59]

terview Survey, 2005

Interventions that have increased SSE through 1-year follow up among the general population have included in person and telephone approaches, videos, pamphlets, and free TCE [83]-[87]. For high risk populations such as melanoma patients and their family members, two UK and US groups have found success at 3-6 months using Skinsafe, an interactive multimedia intervention including characteristics of skin at risk, early signs of melanoma, personalized risk feedback, and SSE instruction [88], [89]. Other interventions have included the approaches used for general populations as well as personalized risk feedback, diaries and body maps, tailored recommendations and reminders, workbooks, a couple-based approach, guided imagery, and the use of photos of moles [75], [88], [90]-[99]. In general, interventions that have significantly increased skin cancer screening have tended to target high risk populations and be interactive and individually tailored based on personal characteristics, attitudes, and behaviors [92], [94].
