Skin of Steel Survey of Skin Cancer Prevention Policy: Policy Trends Excerpt
Researcher:
Sara Nichols, Georgetown University
August 2010
Public Health Trends
· The dangerous connection between ultraviolet light and skin cancer has only recently become a topic of concern.
The National Toxicology Program’s Report on Carcinogens first listed solar radiation and exposure to sunlamps as known human carcinogens in 2000. Broad Spectrum UVR was classified as a known human carcinogen in 2002. UVA, UVB, and UVC are still only reasonably anticipated to be carcinogenic. Until UV exposure was published as carcinogenic with scientific evidence from a trusted source like the Report on Carcinogens, critics could argue that there was no danger from UV exposure. Skin cancer prevention policy has only had a fighting chance to change behaviors for the past 10 years.
The Environmental Protection Agency piloted the SunWise School Program, an environmental and health education program that teaches K-8 students and their caregivers skin and sun safe habits, during the 1999-2000 school year. Also, the Center for Disease Control and Prevention (CDC), a primary public health agency, only started monitoring national skin cancer prevention in 1999. These facts further indicate that skin cancer prevention was not a recognized public health issue until about the 21st century.
· National monitoring of skin cancer prevention is minimal to nonexistant and inconsistent.
Monitoring health issues leads to action and increased policy on that issue. For example, monitoring mental health; collecting data on the prevalence of mental health topics taught in school, how often primary care physicians provided mental health advice, how interested the general public was, etc; led to more mental health policy. Mental health was a lead health indicator in Healthy People 2010. National attention trickles down to state and local levels. In the Illinois State Health Improvement Plan, mental health is now a priority.
Adequate monitoring of skin cancer prevention does not exist. The CDC’s monthly Behavioral Risk Factor Surveillance System included inquires about sunburn in their core questionnaire in 1999, 2003, and 2004. In 1999 and 2000 only optional sun safe practice questions were offered. Only 9 states actually used those optional questions. The most recent survey has optional questions on sunburn and melanoma incidence only. No state has chosen to use these. In addition, the biannual Youth Risk Behavior Surveillance System lists only two optional sun safe questions. The School Health Policies and Practices Study, taken in 1994, 2000, and 2006, has one relevant question. The School Health Profiles, biannual since 1996, asked about the prevalence of sun safety education from 2002-2006. It has now stopped asking these questions without indicating the reason for their absence.
This trend also exists at the state level. The Illinois Youth Survey and the Illinois Project for Local Assessment of Needs (IPLAN) do not monitor skin cancer or its prevention.
Effective health improvement goals cannot be set without baseline data and will not be met without consistent progress reports. This information must be collected for skin cancer prevention. Also, each prominent survey should ask the same, insightful questions so comprehensive data on all populations is gathered.
· When skin cancer prevention is monitored, the survey questions do not collect the most useful information and can send the wrong skin and sun safe message to those surveyed.
Researchers know specifics on the dangers of UV rays and the best protection methods. For example, they know that tan skin represents sun damage, sun caution is necessary even on cloudy days, sunscreen should not be the only protection method used, and baseball hats do not provide adequate shading. This knowledge has not been fully represented in surveys to date.
The School Health Profiles questioned teachers, “During this school year, did teachers in your school teach each of the following physical activity topics in a required course for students in any of grades 6 through 12? Including Weather-related safety (e.g. avoiding heat stroke, hypothermia, and sunburn while physically active)”. The Profiles chose to focus only on the end result, sunburn, and not the behaviors leading up to it.
The 2011 National High School Questionnaire of the Youth Risk Behavior Surveillance System include this optional question, “When you are outside for more than one hour on a sunny day, how often do you wear sunscreen with an SPF of 15 or higher?”. The questionnaire neglected reapplication, tanning bed usage, and appropriate sun protective clothing.
The Behavioral Risk Factor Surveillance System has asked a range of questions throughout the years. Optional modules included questions about protection behaviors when outside for more than an hour on sunny days. The 2010 survey’s only sun safety question asks, “In the past 12 months how many times did you have a red or painful sunburn that lasted a day or more?”. No state has chosen to use this question, perhaps because they realize people will not know the correct answer and that this does not measure sun safety well anyways.
These examples from prominent surveys display a focus on sunburns and sunny days. Resulting data does not indicate whether best practices of skin cancer prevention are used. Even more dangerous, these questions imply to those surveyed that they only have to worry about sun safe behaviors if they will be in the sun for long amounts of time or frequently sunburn. This is not true and leads to unsafe perceptions.
Hope
for better monitoring exists in the National Cancer Institute’s (NCI) Cancer
Trends Progress Report 2009/2010 Update. In 1992, NCI began monitoring the
percentage of adults 18+ who usually or always protect themselves from the sun
with sunscreen, protective clothing, or by staying in the shade. In 2000, NCI
began collecting data distinguishing any SPF level sunscreen and SPF 15+. In
2003 it distinguished truly protective clothing from partially protective hats.
More selective data collection like this would be useful.
· A national focus on wellness and prevention has developed, creating an opportunity for skin cancer prevention to be presented.
America and many states have moved towards creating comprehensive wellness policies and initiatives in the spirit of the World Health Organization’s definition of health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Wellness policies encourage the adoption of preventive health care and provide a framework that skin care prevention could fit into.
The Department of Health and Human Services’ (HHS) Strategic Plan for fiscal year 2007-2012 includes the strategic objective, “Promote and encourage preventive health care, including mental health, lifelong behaviors and recovery”. Within HHS, the Office of Disease Prevention and Health Promotion works to fulfill this goal. Its Healthy People 2010 guide included the goal, “Increase the quality, availability, and effectiveness of educational and community-based programs designed to prevent disease and improve health and quality of life” with 12 specific objectives.
To achieve these goals the “Steps to a Healthier US Initiative” exists. Since 2003, HHS and the CDC have funded communities to implement health promotion programs. They focus on diabetes, obesity, asthma and the underlying issues of physical activity, nutrition, and tobacco use. While this Initiative may not include skin cancer prevention, it demonstrates that wellness and prevention is growing in popularity.
In Illinois, the State Board of Education adopted a State Goal on Wellness. The State Board along with the Illinois Nutrition Education and Training Program provide districts with wellness policy resources including a Local Wellness Policy Toolkit. Further, a School Wellness Policy Taskforce exists by law. While none of these address skin cancer prevention now, they are structures in which skin cancer prevention policy could be included.
· Asthma management policies have become a critical part of public health and wellness programs proving that nontraditional topics can enter the national conscience.
Asthma awareness did not always exist to the large extent that it does now. An increasing incidence rate concerned the United States. Between 1980 and 1994, the prevalence of asthma increased 75% overall and 74% among 5-14 year-olds in the United States. Approximately 15 million people, 5 million under the age of 18, have asthma. Asthma has no cure and is not always well monitored. Every day, 40,000 people miss school or work because of asthma.
There are crucial differences between asthma and skin cancer. Importantly, asthma is not an orphan disease. Also, symptoms of asthma present as soon as one develops the disease, unlike skin cancer, which does not develop until years after UV overexposure. However, Melanoma has a similar alarming incidence rate to asthma. Melanoma incidence soared 50% since 1980 in women under 30. It would be instructive to research how asthma awareness gained such prominence, as a possible model for skin cancer prevention.
· The significant national focus on decreasing obesity inhibits the growth of skin cancer prevention messages and programs.
While multiple policies and initiatives target obesity, the best evidence of United States’ primary focus on obesity is reality TV shows like The Biggest Loser and Celebrity Fit Club. No other health issue is so palpable that a consistent prime time audience exists on major networks, sometimes solely for entertainment.
Programs have focused on increasing physical activity to combat obesity. People are encouraged to play and exercise outdoors. Being outside is more attractive than staying in a gym, so physical activity promoters will encourage outdoor activity as much as possible.
Some promoters incorrectly perceive skin cancer prevention as a message stating the sun is bad and people must stay indoors to protect themselves. Others understand real prevention methods but fear that anything, which makes outdoor physical activity more inconvenient, will dissuade people from exercise. Either way, the obesity agenda will not easily accept skin cancer prevention.
Medical Trends
· Medical associations have clear, comprehensive skin cancer prevention policies but these do not always transfer to primary care physicians’ practice.
The American Medical Association (AMA) strongly supports skin cancer prevention. AMA policies reach many of the facets of skin cancer prevention. Policies support prohibiting minors purchasing tanning salon services, encourage skin cancer prevention education for the general public and children, and recommend that all high school students know how to perform skin self exams.
Despite policies from the American Medical Association and American Academy of Pediatrics, skin cancer prevention advice is not as common as other topics such as substance abuse, sexually transmitted disease, bicycle safety, and seatbelt use. Physicians have a great opportunity to educate about skin cancer during physicals. Annual physicals are recommended, in which physicians could include advice about skin cancer prevention. Children are especially likely to have yearly physicals, which are required to play on many athletic teams.
School Trends
· Schools are in a unique position to make skin cancer prevention the norm but are not currently fulfilling this role.
About 23% percent of lifetime sun exposure occurs by age 18. In addition, one blistering sunburn in childhood or adolescence more than doubles a person’s chances of developing melanoma. Thus, it is crucial that children understand the dangers of UV rays and ways to protect themselves. It is also useful to start this education as soon as possible. Younger children are more likely to absorb messages that can also be reinforced by the child’s caregivers.
Children are in school or after school activities for the majority of the day. This gives schools multiple opportunities to implement skin cancer prevention policies. Schools could provide education in regular classes as relevant or through the health education curriculum, raise awareness through a wellness campaign or the school nurses, schedule recesses and outdoor activities outside the peak hours of sunlight from 11 am-2 pm or ensure the facilities offer adequate shade, allow UV protective clothing in the dress code, etc.
While many guides exist to aid schools in implementing policies, few states or schools have taken advantage of these. In Illinois, the Learning Standards require students to learn about UV exposure and prevention as part of Physical Development and Health. However, it is possible that students will only be tested on this knowledge in fourth grade, if at all.
School policy would be instrumental in a successful skin cancer prevention effort.
Occupation Trends
· Few occupational skin cancer prevention policies exist despite immense sun exposure in certain careers.
Outdoor workers and those in the military are high risk populations for skin cancer because of their above average sun exposure. 60% of Melanomas and 90% of non-Melanoma skin cancers are attributed to UV radiation.
In recognition of this threat, Martin A. Weinstock, Professor of Dermatology at Brown Alpert Medical School, on behalf of the Melanoma Research Foundation, as well as numerous other medical professionals and advocates, requested $10 million for melanoma research in the Fiscal 2011 Defense Appropriation bill. Research will benefit both those in the military and the general population.
While research is conducted, employers can use existing skin cancer prevention guides targeted at outdoor workers. Employers should be responsible for educating their employees. In addition, it is standard for employers to provide necessary personal protective equipment. Sunscreen and UV protective clothing should be included as personal protective equipment.
Recreation Trends
· Throughout tough economic times park districts are utilized more frequently, giving them an opportunity to promote skin cancer prevention.
With tight family budgets, more families are unable to pay for expensive activities or private services such as country clubs, golf courses, or gym memberships. More families take “staycations” in which they spend holidays at home. Thus, more families will turn to park districts for their exercise and recreational needs.
Park districts have an opportunity to educate about skin cancer and provide protection through sunscreen distribution or shade structures at outdoor park district locations. These activities would promote the park districts’ purpose of serving the community. Unfortunately, most park districts are not currently providing these services nor do they have fund to start.
· Shade structures are currently the major focus of skin cancer prevention efforts in recreational settings.
Parks and pools are utilized most often on sunny days, likely by people who are not being skin and sun safe. In addition, schools may find that it is too complex to schedule physical education classes, recess, and sporting events during non-peak sun hours of the day, 11 am- 2pm. For some, using protective methods such as hats or sunscreen could be problematic. Providing shade where outdoor activities already take place may be a good alternative.
Shade structures, whether permanent, removable, or natural, provide protection from UV rays. However, creating new structures is expensive and they must be maintained. To alleviate costs, organizations such as the SHADE Foundation and the American Academy of Dermatology through its Shade Structure Program award grants for communities or schools to build shade structures. These grants can be rewards for excellent skin cancer prevention in a community, provide a great protection method, and further the community’s own educational process.
Indoor Tanning Trends
· Policy discouraging indoor tanning has increased but the tanning industry has a powerful and well-endorsed lobby with which to respond.
In 2009, the World Health Organization’s International Agency for Research on Cancer reclassified tanning beds as “carcinogenic to humans”. Partly pressured by this reclassification, the US Food and Drug Administration held a tanning panel that unanimously agreed tanning beds should not be a class 1 device. Class 1 devices include tongue depressors so this reclassification should not have been such a big leap for the FDA. The panel did not conclude whether tanning beds should be in class 2 or class 3. Most recently, a 10% tax on indoor tanning was implemented through the Patient Protection Affordable Care Act.
Many states are working on increasing the minimum age of minors who are allowed to use tanning beds. Howard County, Maryland was the first community to ban those under 18 from using tanning beds.
Despite this progress, the Indoor Tanning Association is ready to fight back. It claims policy discouraging indoor tanning unfairly targets small businesses with many women employees and university student customers. It also cites that such policy is racist toward its predominantly white, lower income, less educated customer base. The industry has annual estimated revenue of $5 billion and 30 million American customers.
Efficacy of Policy Trends
· When policies exist, they usually correctly identify the major skin cancer prevention methods.
Skin cancer prevention is a comprehensive effort. Most skin cancer prevention policies recognize this and recommend avoiding tanning beds, minimizing sun exposure during the maximum UV exposure times of day, providing adequate shade, use of best available protective clothing including wide brimmed hats, sunglasses, and long clothing, using SPF 15+ sunscreen, but not as the first line of defense, monthly skin self-exams, and annual skin exams by a certified dermatologist.
A notable exception was the Healthy People 2000 Objectives created by the HHS. An objective set a goal to have 60% of Americans consistently limit sun exposure. The objective measured sunscreen, protective clothing, and shade use. Only the use of sunscreen moved towards the target. This indicates over reliance on sunscreen as a protective measure. Medical professionals and scientists warn against using sunscreen as the first line of defense in skin cancer prevention.
· More scientific studies are necessary to examine the effectiveness of skin cancer prevention interventions.
The US Preventive Services Task Force’s Guide to Clinical Preventive Services had insufficient evidence to make a recommendation for or against primary care clinician interventions on skin cancer prevention. The Task Force on Community Preventive Services also found insufficient evidence to make a recommendation in 7 out of 9 intervention types examined. Future intervention programs or policy can be implemented with the justification of a recommendation from these well-respected guides. Skin cancer interventions are not capturing this opportunity because not enough carefully constructed studies exist.
To mark an intervention a success it needs to demonstrate improved health outcomes. This is rare in skin cancer prevention interventions because cancer outcomes occur many years later. Instead, sun protective behaviors can act as proxies for cancer outcomes. However, many studies examined intermediate outcomes such as increased knowledge, changed attitudes, and intentions about sun protection rather than literal sun protective behaviors. Further, many studies had multiple intervention components but did not measure separate outcomes. It is necessary to see which parts of an intervention create certain behaviors. Although there are barriers to a well-constructed study, these must be overcome to properly evaluate interventions.
· While there has been an increase in indoor tanning policy, this may not be effective because of the addictive nature of UV light.
Multiple studies published in the Journal of American Academy of Dermatology, Preventive Medicine, Pediatrics, and Archives of Dermatology have shown that increased knowledge often fails to change tanning behavior and attitudes, especially among teenagers. As a result, researchers have recently questioned whether a UV light substance related disorder could exist. In a 2007 report published in the American Academy of Dermatology, researchers found 12% of undergraduate students scored positively on a modified CAGE questionnaire, which traditionally is used to determine the presence of an alcohol substance-related disorder. They concluded that a significant proportion of college students are addicted to tanning.
In
light of this, policy discouraging indoor tanning may not be sufficient to
impact behaviors. Legislation prohibiting the use of tanning beds for minors
under 18 is recommended.
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