thesis statement on skin cancer

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Senior Honors Theses

Skin cancer: causes, prevention, and treatment.

Lauren Queen Follow

Publication Date

Spring 4-10-2017

School of Health Sciences

Health Promotion: Clinical Track

Skin Cancer, Melanoma, Prevention, Treatment, Dermatology

Disciplines

Diseases | Medicine and Health Sciences | Skin and Connective Tissue Diseases

Recommended Citation

Queen, Lauren, "Skin Cancer: Causes, Prevention, and Treatment" (2017). Senior Honors Theses . 648. https://digitalcommons.liberty.edu/honors/648

The purpose of this thesis is to analyze the causes, prevention, and treatment of skin cancer. Skin cancers are defined as either malignant or benign cells that typically arise from excessive exposure to UV radiation. Arguably, skin cancer is a type of cancer that can most easily be prevented; prevention of skin cancer is relatively simple, but often ignored. An important aspect in discussing the epidemiology of skin cancer is understanding the treatments that are available, as well as the prevention methods that can be implemented in every day practice. It is estimated that one in five Americans will develop skin cancer during his or her lifetime, and that one person will die from melanoma every hour of the day. To an epidemiologist and health promotion advocate, these figures are daunting for a disease, especially for a disease that has ample means of prevention. However, even with sufficient prevention methods, a lack of education and promotion of a practice will not lead to favorable results. This thesis will aim to uncover the causes and treatments associated with skin cancer, the disease, distribution, and determinants of the disease, and finally, how the promotion of the practice of prevention of this disease can be furthered.

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Skin Cancer—The Importance of Prevention

In 2009, the US Preventive Services Task Force (USPSTF) found insufficient evidence to recommend skin examinations for the early detection of skin cancer in adults. The conclusion followed from a systematic review of the effectiveness and harms of clinical visual skin examinations by physicians or patient self-examinations in terms of morbidity and mortality from skin cancer.

Several years later, after another systematic review, 1 the USPSTF’s conclusion—that there is insufficient evidence to recommend total-body skin examination for the early detection of melanoma, basal cell cancer, or squamous cell cancer in all adults—remains the same. 2

The USPSTF’s determination that evidence is not adequate to support a recommendation for skin cancer screening will likely once again disappoint national organizations such as the American Academy of Dermatology and the Skin Cancer Foundation, which have advocated for screening. 3 , 4 Physicians and patients might also be confused. After all, several organizations have encouraged screening; skin cancer seems easy to detect early because it is visible; skin examinations are neither painful nor invasive; and melanoma thickness at the time of diagnosis predicts mortality.

However, the USPSTF recommendations are based on a rigorous evidence review that balanced the benefits and risks of screening. The potential benefits are apparent but the risks, such as unnecessary procedures and their downstream complications, may not be. Over treatment of skin cancer may be especially problematic for patients with limited life expectancy due to old age or comorbidities. These patients may not live long enough to benefit from more intensive treatments but may be at risk for short-termtreatment-relatedcomplications. 5

The USPSTF review identified no completed randomized clinical trials on the topic. The USPSTF rightly focused on the initially exciting results of an ecologic study, Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany (SCREEN), conducted in 1 German state during 2003–2004. 6 The SCREEN study showed a 48% relative reduction in melanoma mortality in the state by 2009 after initiation of a population-based skin cancer awareness campaign, clinician education and training, and screening of nearly 20% of eligible adults aged 20 years and older with a single clinical visual skin examination. Those results prompted Germany to institute a nationwide program of clinical visual skin examinations. Unfortunately, the mortality benefit was not sustained with further follow-up, and several major methodological concerns about SCREEN have been raised. 7 , 8

Skin Cancer Is a Major Problem

The incidence of skin cancer is higher than that of all other cancers combined. Both melanoma and nonmelanoma skin cancer incidence rates continue to increase. The 5.4 million new cases of basal and squamous cell carcinomas in the United States annually 9 and 76 380 new cases of malignant melanoma each year 10 raise concerns for both patients and the health care system. Skin cancer treatments cost the United States more than $8 billion each year, making skin cancer the fifth most costly cancer for Medicare. Furthermore, skin cancer is an under recognized problem for diverse populations, including young women and minorities such as Hispanic individuals and gay men.

If universal screening is not the right approach, what can we do? The answer is that we can do a lot, if we shift our focus from secondary prevention (catching a cancer early enough to treat it) to primary prevention (preventing the cancer from developing in the first place). More than half of cancers are considered preventable through behavioral changes, vaccinations, or medications. 11 The evidence suggests that much of skin cancer could also be prevented.

Preventability of Skin Cancer

The UV radiation from indoor tanning beds is a group 1 carcinogen, in the same category as tobacco or asbestos. 12 Preventing carcinogenic exposures can result in preventing cancer. Indoor tanning is estimated to cause more than 450000 new skin cancers, including more than 10000 melanomas, each year. 13 Despite substantial investment in prevention efforts, including several well- designed campaigns by the Centers for Disease Control and Prevention and foundations focused on skin cancer prevention, efforts to affect the incidence of skin cancer have hit a brick wall. Tanning bed use remains common, with 1 in 5 adolescents and more than 40% of college students using tanning beds. 13

What are we doing wrong? In part, we might not be using the right tools to reach teens and young adults directly, and we might not be reaching the mat the right time. That is where technology may help. Social media and online search engines provide the ability to target health messages directly to those at highest risk. These platforms provide away to introduce messages precisely when teens are, for example, searching for a tanning salon. 14 Technology that targets health messages can get the right message to the right person at the right time. Refining messages that can shift social norms about tanning in general and studying whether these can actually change behaviors remain priorities.

Established and effective strategies for skin cancer prevention are also underused. Comprehensive sun-protection programs that emphasize shade and sun-protective clothing such as Australia’s SunSmart program ( slip on clothing, slop on sunscreen, slap on a hat, seek shade, and slide on sunglasses) should be implemented widely. The Australian program has been linked to a decrease in the incidence of skin cancer in young adults. 15 , 16 Strategies that go beyond education and address practical, environmental, and behavioral barriers to sustainable sun protection have the highest likelihood of success. Shade structures in playgrounds and free sunscreen dispensers in outdoor parks are innovative ideas that should be evaluated. In addition, there are lessons from successful antismoking efforts. Based on the experience with smoking cessation programs, increasing the legal age for indoor tanning to 21 years, restricting indoor tanning advertising directed to youths, and increasing taxation for indoor tanning beyond the 10% excise tax imposed by the Patient Protection and Affordable Care Act may be effective approaches. Physicians and the public should remain alert to the indoor tanning industry’s use of the same techniques used by the tobacco industry: paying scientists to bring doubt to the evidence, making false advertising claims about the health benefits of tanning, and undermining the scientific consensus on the adverse health effects of indoor tanning.

Does Skin Cancer Screening Make Sense for High-Risk Individuals?

As new data emerge, we might find that the benefits of skin cancer screening outweigh the risks for high-risk individuals. Such individuals include solid-organ transplant recipients who have 3 times higher risk of developing malignant melanoma and more than 60 times higher risk of cutaneous squamous cell carcinoma. They also include people with a history of multiple skin cancers whose probability of developing another skin cancer is 50% within 1 year and 70% within 3 years of their last skin cancer diagnosis as well as people with a strong family history of melanoma. As more is learned about the genetic predictors of melanoma and other skin cancers, genotypic approaches may be developed to stratify and identify individuals at high risk who could benefit from screening.

Conclusions

The USPSTF recommendations should not be misinterpreted as minimizing the importance of skin cancer. Instead, the report should motivate us to improve the evidence base for identifying groups of people in whom the benefits of screening might outweigh risks. We need high-quality, long-term randomized clinical trials of the effectiveness of screening on skin cancer prevention. Meanwhile, we should also fully implement skin cancer primary prevention by eliminating indoor tanning exposure, especially among youths, and increasing the use of sun-protection strategies that work.

Conflict of Interest Disclosures: None reported.

Skin Cancer: Description, Causes, and Treatment Research Paper

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Skin cancer is one of the most common types of cancer; the three most common types of skin cancer are basal cell carcinoma, squamous cell carcinoma, and melanoma. Skin cancer incidences gradually increased in the last decades, presenting a significant threat to the population’s well-being (Cameron et al., 2019). Skin cancer is characterized by an uncontrollable growth of skin cells, during which they could spread to other human body parts and cause damage. According to Cameron et al. (2019), a higher percentage of risk of developing skin cancer (20% to 30%) is associated with the white population. The review conducted by Kim et al. (2019) suggests that skin cancer prognosis could be connected with light eye color and freckles combined with red or blonde hair color. Family history of skin cancer and continuous exposure to direct sunlight, photosensitizing drugs, or carcinogenic chemicals also contribute to skin cancer development. Millions of people are diagnosed with nonmelanoma skin cancer in a span of one year, and mortality rates are estimated at 0.12 per 100,000 cases (Kim et al., 2019). In general, the main risk of developing skin cancer is UV radiation and exposure to sunlight.

Dermatologists or physician assistants could diagnose skin cancer through biopsy, which allows fast and accurate results. Depending on the size and shape of the tumor, the diagnosis could be performed either through a punch biopsy or a shave biopsy, designed for larger areas of skin. Moreover, shave biopsy allows a more accurate result due to the decreased chance of sampling error (Cameron et al., 2019). Non-invasive options for skin cancer diagnosis include optical methods, such as coherence tomography and reflectance confocal microscopy (Cameron et al., 2019). Both methods operate based on infrared light projection and could also be used to provide an accurate result.

Treatment of skin cancer is primarily focused on the local excision of tumors. However, the excision does not guarantee the full elimination of disease as recurrences could occur significantly later after the initial treatment. According to Kim et al. (2019), recurrence rates or surgical excision are between 3 to 12 percent of cases, and they mostly take place more than five years post-treatment. Therefore, besides the initial treatment, the necessary measures also include follow-up checkups.

Currently, there are many available options for skin cancer treatment. Surgical excision is recommended for tumors located in neck and trunk areas. Incomplete excisions in surgical treatment could result in recurrence in approximately 38 percent of cases (Kim et al., 2019). Mohs surgery is recommended for the treatment of high-risk tumors and recurrent skin cancer. On the other hand, for low-risk tumors, treatment measures could be faster and more cost-effective, with methods such as electrodesiccation and curettage (Kim et al., 2019). One of the treatment procedures developed recently for low-risk skin cancer tumors is cryosurgery, which focuses on freezing the surrounding margin of the tumor. Overall, the choice of treatment is based on the size of the tumor, its location area, and available equipment.

As skin cancer is associated with UV radiation, it is recommended that the population, especially those with a higher risk of developing skin cancer, take preventative measures. The preventive methods include reducing time spent in direct sunlight, wearing protective clothing and equipment, and using sunscreen products that reduce the harm from UV radiation. Lastly, it is necessary to educate the population on the importance of regular self-skin examination and prompt turn to professionals for a diagnosis to prevent adverse outcomes.

Cameron, M. C., Lee, E., Hibler, B., Giordano, C. N., Barker, C. A., Mori, S., Cordova, M., Nehal, K. S., & Rossi, A. M. (2019). Basal cell carcinoma: Contemporary approaches to diagnosis, treatment, and prevention. Journal of the American Academy of Dermatology, 80 (2), 321-339. Web.

Kim, D. P., Kus, K. J. B., & Ruiz, E. (2019). Basal cell carcinoma review. Hematology/Oncology Clinics of North America, 33 (1), 13–24. Web.

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IvyPanda. (2022, December 21). Skin Cancer: Description, Causes, and Treatment. https://ivypanda.com/essays/skin-cancer-description-causes-and-treatment/

"Skin Cancer: Description, Causes, and Treatment." IvyPanda , 21 Dec. 2022, ivypanda.com/essays/skin-cancer-description-causes-and-treatment/.

IvyPanda . (2022) 'Skin Cancer: Description, Causes, and Treatment'. 21 December.

IvyPanda . 2022. "Skin Cancer: Description, Causes, and Treatment." December 21, 2022. https://ivypanda.com/essays/skin-cancer-description-causes-and-treatment/.

1. IvyPanda . "Skin Cancer: Description, Causes, and Treatment." December 21, 2022. https://ivypanda.com/essays/skin-cancer-description-causes-and-treatment/.

Bibliography

IvyPanda . "Skin Cancer: Description, Causes, and Treatment." December 21, 2022. https://ivypanda.com/essays/skin-cancer-description-causes-and-treatment/.

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What influences the uptake of information to prevent skin cancer? A systematic review and synthesis of qualitative research

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Ruth Garside, Mark Pearson, Tiffany Moxham, What influences the uptake of information to prevent skin cancer? A systematic review and synthesis of qualitative research, Health Education Research , Volume 25, Issue 1, February 2010, Pages 162–182, https://doi.org/10.1093/her/cyp060

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Skin cancer is an increasing problem in Europe, America and Australasia, although largely preventable by avoiding excessive ultraviolet (UV) exposure. This paper presents the findings of a systematic review of qualitative research about the prevention of skin cancer attributable to UV exposure. The aim is to understand elements that may contribute to the successful or unsuccessful conveyance of skin cancer prevention messages and their uptake by the public. A systematic review was undertaken using evidence identified through searching electronic bibliographic databases and Web sites and reference list checks. Predefined inclusion and exclusion criteria were used. Sixteen study reports (relating to 15 separate studies) were included from the United Kingdom, United States, Australia, Canada and New Zealand. Each included study was quality appraised, and the findings were extracted into an evidence table. A coding scheme, framed by the Health Belief Model, was developed by the reviewers and informed analysis and synthesis. This showed that most people perceived their susceptibility to skin cancer, and its severity, as low. While benefits of adopting changed behaviour were acknowledged, there were substantial barriers to this, including positive perceptions of a tan as healthy and attractive and the hassle of covering up or using sunscreen. Peers, parents and media may offer ‘cues to action’ that encourage adoption of preventative behaviour and finally self-efficacy or the perceived ability to make such changes. Effective health education messages will need to address the barriers to adopting protective behaviours identified through this review.

Exposure to ultraviolet (UV) light radiation, particularly that resulting in burning, is the leading cause of skin cancer. Risk is related to individual factors, for example, those with pale or fair skin and/or a large number of moles, as well as exposure either to strong sunlight or tanning beds [ 1 ]. Skin cancer is the most common UK cancer, with ∼81 700 cases of non-melanoma registered in 2006 (rate 94.9/100 000 population) and 10 400 malignant melanoma cases diagnosed (14.7/100 000): the latter represents a quadrupling of incidence rates since the 1970s, raising faster than any other cancer [ 2 ]. Globally, the highest rates are in New Zealand and Australia. It is known that many cases of skin cancer would be preventable through simple observations such as avoiding excessive sunlight, using UV filters in sunscreen and covering up with hats and clothing.

This paper reports a systematic review and synthesis of qualitative research which aimed to address two key questions:

What factors help to convey information to prevent the first occurrence of skin cancer attributable to UV exposure?

What factors hinder the communication of such primary prevention messages?

The review was commissioned by the Centre for Public Health Excellence at the National Institute for Health and Clinical Excellence (NICE) as part of a series of reviews which would be used to inform public health policy making around the issue of information provision to prevent skin cancer. However, the nature of the research which we identified meant that a broader scope was considered. In particular, we wanted to understand how people understood tans and tanning in order to contextualize their behaviour in response to health education messages.

Identification of evidence

A search strategy, using combined thesaurus and text word terms associated with skin cancer and providing public information and a qualitative studies filter, was used in MEDLINE, EMBASE, The Cochrane Library, PsycINFO, ASSIA, CINAHL and HMIC. Full details are shown in   Appendix 1 . Titles in the reference lists of included reports were also checked.

We included any English language study that used qualitative research methods to collect and analyse information about skin cancer prevention in Organisation for Economic Cooperation and Development countries, published between 1990 and September 2009.

Titles and abstracts were screened for inclusion using a predefined checklist (see   Appendix 2 ). Twenty percent of the hits were screened by a second reviewer (M.P.). Full text study reports were checked for inclusion by two reviewers independently (R.G. and M.P.) and disagreements resolved by discussion.

Quality assessment

All included studies were assessed for quality using criteria suggested by Wallace et al. [ 3 ]. Assessment was undertaken by one member of the team and checked by another, with disagreements resolved through by discussion.

Data extraction

For each included study report, information about methods, participants and findings (in the form of key themes, concepts and metaphors) were extracted by one reviewer (R.G. or M.P.).

Data analysis and synthesis

Two reviewers (R.G. and M.P.) read and re-read the extracted findings. Four included studies used the Health Belief Model [ 4 ] and this offered a coherent framework to interpret and synthesize findings from most of the included studies. We therefore used this as the starting point for developing codes to analyse the findings, and related sub-themes were developed through further reading and coding. Extracted findings were coded using this framework and similar codes drawn together in a narrative which synthesized the study findings. This method was informed by meta-ethnographical approach of translation, whereby the findings of one study are understood in terms of another and linked to produce a line of argument [ 5 , 6 ]. In this case, most papers were not conceptually well developed, summarizing findings in the form of themes. We used the structure of the Health Belief Model as the conceptual lens through which these themes were assessed and ‘translated’ findings into this framework.

Identified studies

Study identification is shown in Fig. 1 .

Review flowchart

Study characteristics

Sixteen study reports, reporting on 15 research projects, were included in the review (see Table I ). Two reports were based on the same study interview data [ 7 , 8 ]. Summary details are shown in Table I . Five studies are from the United Kingdom [ 9–13 ], four studies from the United States [ 14–17 ], three are Australian [ 18–20 ] and there was one study each from New Zealand [ 21 ] and Canada (resulting in two study reports [ 7 , 8 ]). One study report compares policies in Australia, Canada and the United Kingdom [ 22 ].

Summary of identified study reports

FGDs, focus group discussions; HP, health promotion; KAP, knowledge, attitudes and practices.

Methodological details are summarized in Table II . The majority of study designs were appropriate for investigating the research questions stated, although the lack of reporting detail meant it was often impossible to assess whether specific quality criteria had been met. For example, five reports did not provide sufficient information to assess whether the sample was adequate to explore the range of subjects and settings, and seven did not provide sufficient information to assess whether data collection had been rigorously conducted. Nine reports did not say how ethical issues had been considered or addressed. Quality appraisal for each study is shown in Table III .

Methodological details of included studies

PTO, Parent/Teacher organisation.

Quality appraisal of included studies

Y, yes; N, no; CT, cannot tell; NA, not applicable.

Analysis and synthesis

The Health Belief Model, used as a conceptual framework by four included study reports [ 13 , 15 , 18 , 23 ], framed our synthesis of the findings. Within its core areas—perceived susceptibility to skin cancer, perceived severity of skin cancer, perceived benefits of skin cancer protection behaviour, perceived barriers to sun-safety behaviour, cues to action to take preventative action against skin cancer and self-efficacy [ 24 ]—we developed more detailed codes through repeated readings of the study findings ( Table IV ).

Health Belief Model with Extended Analytic Themes

Perceived susceptibility

Four studies discuss perceived susceptibility to skin cancer [ 13 , 18 , 21 , 23 ]. Three, among children (up to 16 years old) and older adults (>55 years), discuss low perceived susceptibility to skin cancer [ 13 , 18 , 23 ]. Children saw skin cancer as a problem encountered in adulthood, currently irrelevant to them [ 18 ]. Children felt they were at risk of sunburn but that this lasted only a few days, without long-term repercussions [ 23 ]. Some older adults did not acknowledge susceptibility to skin cancer because they did not smoke, had general good health, no family history or because of the relatively low temperatures in the United Kingdom [ 13 ].

Three studies, among both children and adults, show the belief that fairer skinned people were most at risk, with a darker skin colour seen as protective [ 13 , 21 , 23 ].

Perceived severity

Six studies discuss different populations’ perceptions of the severity of skin cancer [ 11 , 13 , 15 , 18 , 19 , 23 ]. Perceived severity of the harm related to UV exposure was largely low in children (United States [ 18 , 23 ]), young adults (United States [ 15 ]), older adults (United Kingdom [ 13 ]) and sunbed users (United Kingdom [ 11 ]), suggesting a lack of distinction between malignant and non-melanoma.

Children did not understand about skin cancer and perceived only immediate and temporary undesirable effects of sun exposure such as a headache or sunburn [ 23 ]. In the same US study, parents were unconcerned about development of skin cancer ‘spots’, believing that their surgical removal was always curative [ 23 ].

I'll deal with it when it happens, you know, 50 years or so (participant, Gerbert et al. [ 15 ]).

Well I mean, the obvious risk is skin cancer but I tend not to think about it, you just put it to the back of your mind and hope that you won't get it (participant, Murray and Turner [ 11 ]). Doesn't do any good thinking about it (participant, Wright and Bramwell [ 13 ]).

Sunbed users acknowledged that they were placing themselves at risk but they also believed the short-term benefits of tanned skin outweighed long-term risks [ 11 , 18 ]. This is expanded in the section on Perceived barriers below.

Cancer versus aging

Photoaging, such as wrinkled skin, was taken seriously by participants in four studies [ 11 , 15 , 18 , 19 ], with more concern seen among women [ 16 , 11 ]. In some cases, the risk of such damage was viewed as more ‘real’ and serious than skin cancer [ 15 ]. Two studies suggest targeting this concern about appearance in sun-safety campaigns to motivate behaviour change [ 15 , 18 ].

Perceived benefits

Eight study reports discuss the perceived benefits of UV protection behaviour [ 7 , 9 , 11–13 , 18 , 19 , 23 ]. In most cases, this was related to understandings of the risks of sun exposure.

Two Australian studies report that children and adolescents were able to list damaging effects of excess sun, including skin cancer [ 18 , 19 ], and were aware of the benefits of limiting skin exposure [ 18 ]. By contrast, Glanz et al. [ 23 ] reported that elementary children in the United States did not understand skin cancer or its associated risks. The ‘Me No Fry’ media campaign (Australia) had been seen by almost all the participants (aged 11–16 years) in the study of Lupton and Gaffney, with its primary message being understood as ‘covering up’ to avoid sun damage [ 19 ].

Parents understood the importance of starting sun-protection practices with children at a young age to cultivate the habit (Hawaii, USA [ 23 ]). Parents, children and recreation staff agreed that use of sunscreen was the most important component of protective behaviour [ 23 ].

Adult participants in Carter's Scottish study saw health education about sun protection as credible and were easily able to repeat the benefits; however, their behaviour did not follow the advice [ 9 ]. Carter suggests that behaviour is influenced to a far greater degree by social expectations about tanning (see Positive perceptions of tans below). In contrast, some adult participants in the Yorkshire study of Tones et al. were keen to practice sun safety but asked questions that indicated confusion over effective practices [ 12 ].

Older adults (>55) varied in understanding skin cancer causes. Whilst most identified sunlight or UV as the main cause of skin cancer, some had imprecise understandings of this link (for example, believing that sunbeds constituted a greater risk than ‘ultraviolet light’—participant quote) or erroneous beliefs (for example, believing that skin cancer was contagious or caused by oriental food or perfumed soap [ 13 ]).

Four study reports show inaccurate belief that a tan is protective of skin damage: among parents discussing their children in Hawaii, adolescents in Canada and adults in the United Kingdom [ 7 , 11 , 12 , 23 ]. This was used to justify using a sunbed before a holiday [ 11 ]. Two study reports show that getting burnt was thought to be the prelude to a deep tan [ 9 , 19 ]. In addition, high sun-protection factor sunscreens are seen as preventing a tan, leading to lower factors being used or periods in the sun without any protection to allow a tan to develop [ 19 ]. These perceptions work against sunscreen adoption, since it is seen as preventing the deep tan regarded as protective, as well as desirable.

Perceived barriers

Most of the reported findings of the included studies can be thought of in terms of perceived barriers to sun-protection behaviour. These barriers relate to five key areas which were used to code themes in the papers, within which sub-themes were also developed ( Table IV ), and provide the structure for the following section.

Framing and narratives of sun safety in Australia, Canada and the United Kingdom

Source: Garvin and Eyles [ 22 ] Table I (p. 1181).

Positive perceptions of a tan

Tans are healthy..

Seven studies report that tanned people are seen as healthy by children, adolescents and adults [ 7 , 9–11 , 15 , 19 , 21 ]. Tanned skin was considered part of a healthy lifestyle, such as enjoying the outdoors [ 15 , 19 ] and being able to holiday in sunny, foreign locations [ 9 ]. Carter suggests that, in a consumer society, ‘health’ is understood more in terms of the ‘appearance’ of health than in the avoidance of danger [ 9 ].

Children with suntans look healthy, they look lovely. (participant, Goodlad et al. [ 10 ]).

If you're fit, healthy and white it's just not quite the same (participant, Reeder et al. [ 21 ]).

Sunbed users justified such use because they believed that tanned skin improved appearance and made them feel healthier [ 11 ].

I think they [the media] send out that … you should go sunbathing because you look a whole lot better and in all the ads in magazines you see bronze, athletic people and they look so much better … I don't know … I think they are encouraging us to go sun tanning (participant, Shoveller et al. —edit in original [ 7 ]).

The ‘nice healthy glow’ (participant, Murray and Turner [ 11 ]) provided by a tan was contrasted to perceptions of white, untanned skin. One Californian study also reports that the sun was positively seen as a source of vitamin D [ 15 ].

Meanings of pale skin.

Three study reports (from Scotland, Australia and Canada) describe negative associations with white, untanned skin, which was described as unhealthy, artificial, sterile, like a ‘milk bottle’, like a ghost and indicative of being a ‘couch potato’ (participant quotes [ 7 , 9 , 19 ]).

… white legs come out, I'm ashamed to be Scottish … it's like if you see a group of peelie wally people then they are Scottish (Carter [ 9 ]).

An Australian study also found that pale skin was associated negatively with being a Pom (British) while a tan was associated positively with being Australian [ 19 ]. This same study was also the only one to report that a white-skinned role model was identified. Madonna was mentioned in this context, although her pale skin was seen as an indication of her individuality [ 19 ].

Tans are attractive.

Seven studies describe tanned skin as being physically attractive [ 7–11 , 18 , 19 ].

Four studies, among adolescents, young adults and sunbed users, report that tanned skin increased participants’ self-perception of attractiveness, increasing both psychological well being and social confidence among peers [ 7 , 9 , 11 , 18 ].

I feel that I have a lot of bodily imperfections and that by having a tan it makes them seem less obvious … I also think that it makes me more outgoing somehow … that may sound stupid but it does have that effect on me and my personality (participant, Murray and Turner [ 11 ]—reviewers’ edit). For some reason, brown fat looks nicer than white fat (female participant, Young et al. [ 8 ]).

In addition, two studies, one among sunbed users, showed a perception that bad skin and acne were cleared up by UV exposure [ 9 , 11 ].

Your clothes look good if you've got a tan … every summer before people go on holidays … everyone buys them in mind of when they've got a tan (participant, Carter [ 9 ]).

This behaviour, treating tanned skin as a fashion accessory, highlights the tan as a commodity [ 9 ].

Tans signify a good holiday.

First day back at work … everyone says ‘WOW! Have you been on your holidays?’ (participant, Carter [ 9 ]—edit in original). I think if you go abroad as well, you want to come back with a suntan, so people know you've been abroad (participant, Goodlad et al. [ 10 ]).

Carter interprets the tan as a ‘symbolic artefact’ or ‘souvenir’ to take home (author quotes), which is a symbol of tourist consumption and one that is all the more pressing in countries, like Britain, where good summer weather cannot be guaranteed [ 9 ].

Peers views of tans.

Peers are an important influence on UV exposure reported in three studies [ 7 , 11 , 18 ]. Those using sunbeds said that they did so to fit in with their companions if going on holiday [ 11 ]. Two studies, among adults and adolescents in the United Kingdom and Canada, reported that tans gained them a positive response from peers [ 7 , 11 ]. However, there was a fine line, with tans that were considered too dark criticized as well as those thought too pale: adolescents in Canada reported comparison with each other to establish what was appropriate [ 7 ].

More helpfully from a prevention perspective, one Australian study reports that children and adolescents would encourage a friend to cover-up if they were getting burnt [ 18 ].

Hassle of protection

Sun protection can be gained using a number of methods; however, one US study noted that sunscreen was the most mentioned method and suggests that additional methods should be given greater prominence in campaigns [ 23 ]. Australia's ‘Slip, Slap, Slop’, for example, relates, respectively, to covering up, wearing a hat and wearing sunscreen. However, a Canadian study suggests that, as adolescents are concerned about their image, they are most likely to comply with using sunscreen rather than covering up by wearing hats or long sleeves [ 7 ].

Seven studies discuss barriers to sunscreen use [ 9 , 10 , 14 , 15 , 18 , 21 , 23 ].

Sunscreen is seen as expensive [ 10 , 14 , 15 , 21 , 23 ], messy [ 15 ] or time consuming to apply [ 18 , 23 ] and could cause irritation or allergies [ 14 , 15 , 18 ]. Possible long-term negative consequences of sunscreen use, including cancer, are mentioned by two studies [ 15 , 21 ]. A lack of authoritative information about sunscreen use is reported by one study [ 21 ].

They won't do it themselves; they just stand there, arguing while you put it on (participant, Goodlad et al. [ 10 ]).

In addition, school teachers in the United States were concerned about the practicalities of putting sunscreen on children before outdoor activities, including gaining parental permission, monitoring use and the effort of doing it. Expense and allergies were also mentioned [ 14 ].

Two studies [ 9 , 15 ] reported resistance to sunscreen because it was felt to prevent ‘the ultimate tan’ (participant quote, Carter). Conversely, one respondent reported burning despite using sunblock [ 10 ].

Four studies report on the impracticalities of wearing a hat [ 18 , 19 , 21 , 23 ]. Hats were felt to restrict activity such as sports [ 23 ], while younger children might take them off [ 21 ]. Parents also reported that they did not like to wear hats but that children noticed if they did not [ 21 ].

In Australia, younger children were more likely than older ones to wear hats [ 18 ] although hats were more likely to be worn if, like baseball caps, they were seen as fashionable [ 18 , 19 ]. Parents in New Zealand wanted caps to be part of school uniform [ 21 ]. It was noted in another study, however, that as soon as baseball caps became part of a school uniform, they lost their positive connotations [ 19 ].

Long sleeves/covering up.

Five studies discuss aspects of physically covering skin up [ 10 , 18 , 19 , 21 , 23 ]. Three studies report that wearing long-sleeved tops was seen as too much by most, causing discomfort in the heat [ 18 , 19 , 23 ]. Two studies (among adults and adolescents) add that fashion was the crucial concern [ 19 , 23 ].

At the beach, rash suits and wetsuits are favoured by parents for children because they are quick drying and negate the need for sunscreen [ 21 ]. This may address another reported concern that young children repeatedly remove their T-shirts [ 10 ].

Structural challenges to sun protection in schools.

Three studies, all relating to protection of children in schools, note structural or policy issues relating to skin cancer prevention [ 14 , 18 , 23 ]. One Hawaiian study suggests that a willingness to ensure scheduled outdoor activities do not take place at the hottest time of day [ 23 ] although two others (one United States and one Australian) note that there is limited ability to change scheduling around lunchtime [ 14 , 18 ]. Provision of shade outside was seen as a possible improvement [ 14 , 23 ], although this was costly [ 14 ] and anyway not always easy to use by pupils [ 18 ].

Limits of adult responsibilities

Five studies describe the responsibility of parents for their children's safe-sun behaviour [ 8 , 14 , 17 , 21 , 23 ]. Younger children are dependent on their parents for sunscreen and other protection [ 8 , 23 ]. Although parents were role models for their children's behaviour, they did not always exhibit sun-safe habits [ 21 , 23 ] and might themselves be ambivalent about their own desire to be tanned [ 8 ]. It was also noted that parents are not always with their children to ensure their safe-sun behaviour [ 17 ].

School and recreation workers recognized their potential role in educating parents [ 14 , 23 ], although parental participation [ 14 ] and lack of knowledge themselves [ 23 ] were potential barriers.

School teachers.

One study suggests that there are a number of barriers to teachers’ involvement in protecting children from the sun at school [ 14 ]. If they are to provide education about safe-sun behaviour, it needs to be decided who should teach it, to whom and how often and other responsibilities may be overwhelming for teachers [ 14 ]. In addition, liability if children were to get sunburnt or if they were allergic to sunscreen also needs to be considered [ 14 ].

Teenagers versus younger children.

Five studies note that the transition from child to adolescent is marked by increasing independence, or rebellion, and that this may have negative effects on safe-sun behaviour [ 7 , 8 , 18–20 ]. This is because parents’ advice was no longer always followed [ 19 ] as adolescents took more responsibility for their own behaviour [ 8 , 19 ] and they began to experiment with ‘intentional tanning’ (study author quote)—that is, actively seeking a tan rather than getting one incidentally as a result of activity outside [ 7 ]. In addition, media campaigns such as Slip Slap Slop, that had been seen as relevant when they were children, came to be regarded as ‘simplistic’ and less credible as they got older [ 20 ].

Being outdoors

Being outdoors was seen positively in seven studies, for children and adults alike [ 7 , 10 , 15 , 18 , 19 , 21 , 23 ], and may be linked to perceptions of the tan as healthy, discussed above. In particular, what Shoveller et al. [ 7 ] refer to as ‘incidental tanning’ may have particular challenges when considering sun protection. Incidental tanning is that obtained by being outside, while not actively seeking a tan, or not somewhere, like the beach, that is strongly associated with the risk of sunburn. More relaxed attitudes to this incidental sun exposure mean that sunscreen is less likely to be used on overcast days [ 15 ], in the winter (in Australia and Hawaii [ 18 , 23 ]) and for children when going out to play somewhere other than the beach [ 23 ] or for less time than all day [ 18 ]. Two studies suggest that sunscreen is seen by children and adolescents as interfering with the spontaneity of outdoor activity [ 7 , 21 ]. One UK study suggests that people are more likely to use sunscreen when on holiday abroad than when in their home country [ 10 ].

In addition, one study suggests that young men are more likely to seek a tan incidentally, seeing sunbathing as a passive, vain, ‘unmasculine’ activity (author quote [ 19 ]).

Cues to action

Eleven studies discuss cues to action to protect themselves from sun exposure. These include the positive influence of parents and other adults and peers [ 18 , 19 , 23 ], knowing someone who has had skin cancer [ 8 , 10 , 15 , 18 ] and media campaigns [ 10 , 12 , 13 , 15 , 17–21 ].

Sources of encouragement

Three studies, all among children or adolescents, discuss sources of encouragement or role models to adopt safe-sun behaviours [ 18 , 19 , 23 ]. Parents were key for younger children, with primary school children in Australia and the United States reporting that behaviour in the sun was influenced by parents and other adults such as coaches, teachers or youth workers [ 18 , 23 ]. Most students in one Australian study did not believe that their parents were interested in getting a tan; some had previous skin cancer removed [ 18 ]. Older children are more influenced by their peers [ 18 ]; indeed, students in an Australian study were critical of sunburn, labelling those with it as irresponsible people who did not care about their skin [ 19 ].

It was suggested by both parents and recreation staff that children were less resistant to protection and wearing protective clothing when it was made routine. Further, as regular water consumption was already routine during outdoor sports, this was identified as a possible opportunity to also address sun safety [ 23 ].

Knowing people who have had skin cancer

Four studies suggest that knowing someone who had skin cancer was motivating to take more care [ 8 , 10 , 15 , 18 ]. Gerbert et al. [ 15 ] found that more of those who were classed as having high concern about sun protection knew someone who had skin cancer while only one of the low-concern groups did.

Media campaigns

Nine study reports discuss aspects of media campaigns about skin cancer prevention [ 10 , 12 , 13 , 15 , 17–21 ] in four of which the focus of the study was one of three specific campaigns; Slip Slap Slop [ 20 ], Me No Fry [ 19 ] or a Yorkshire TV advertisement [ 10 , 12 ].

Adolescents viewed the general mass media portrayal of tans as appealing [ 18 ], and this was supported by Californian adults with low concern about sun safety [ 15 ]. This latter group associated information about increased UV risk with the impact of a depleted ozone layer. By contrast, those in the same study who were categorized by researchers as having high concern about sun safety were aware of a lot of publicity about the potential personal negative affects of sun exposure, though whether this concern motivated notice of the publicity or vice versa is unknown [ 15 ].

You don't pay attention because you have seen it so many times; you need new stuff all the time (participant, Lupton and Gaffney [ 19 ]).

Four studies suggested that children were receptive to sun-safety messages portrayed in a fun way, such as hat making in the classroom [ 23 ] or humorous or cartoon advertisements [ 10 , 19 , 20 ]. Similarly, some children liked adverts with catchy jingles [ 12 , 20 ], and the positive portrayal of people having fun while adhering to safe-sun practices [ 19 ]. However, criticism about campaigns, particularly from older children and adolescents, included those seen as unrealistic [ 19 ], uncool [ 20 ] or having ‘corny’ jingles (participant quote [ 20 ]) or simplistic messages (particularly as cartoons [ 20 ]). One study suggested that more graphic ‘shock’ images would be preferred, especially by older boys [ 20 ], although adults in UK study did not think frightening people appropriate, although they did feel that people lacked sufficient knowledge about skin cancer [ 13 ].

Self-efficacy

Two UK studies explicitly address self-efficacy in skin cancer prevention with some participants reporting examining themselves for signs of skin cancer [ 9 , 13 ]. Skin cancer is understood as largely preventable and identifiable early by those taking personal responsibility for their skin. Based on participants’ comments about monitoring their sun exposure and, especially, the moles on their skin, Carter provides an explanatory framework about the sun-safety behaviour of adults [ 9 ]. He suggests that sun-safety behaviour is a type of self-surveillance and a personal responsibility. He interprets this in terms of Foucault's ‘disciplinary gaze’, with state surveillance replaced by the individual who shows self-monitoring behaviour (Foucault [25]). Carter suggests that this can be thought of as a ‘non-risk reduction strategy’ (author quote) whereby people can maintain risky behaviour as long as they monitor themselves closely enough [ 9 ].

Comparison of skin cancer policies in Australia, Canada and the United Kingdom

The study of Garvin and Eyles [ 22 ] was not amenable to synthesis using the Health Belief Model and did not contribute any findings to the framework. It was felt important to consider the papers, albeit separately, because it is a well-developed analysis which is relevant to considerations of how relevant and applicable findings from different countries might be.

The authors use the analytic constructs of framing (developed from Goffman [26] and by Entman [27]) and narrative to understand differences in the construction of skin cancer public health policy in Australia, Canada and the United Kingdom [ 22 ]. Framing is a technique to define a problem, diagnose the causes, make a moral judgement on the issues and suggests potential remedies. Frame theory states that people in a given society share a set of symbols, beliefs and images that act as interpretive schemes for making sense of the world—these frames are interpretive constructs in which to order experiences in, and responses to, the environment. Over time, and through day-to-day activities of actors involved in the problem, issues and solutions become integrated into existing frames and develop storylines of their own which become the accepted definitions of problems and can be considered as policy narratives. In highly contested areas, competing frames may vie for control of the dominant narrative.

According to Entman, an issue is continually framed and re-framed with ‘communicators’ describing what to say based on underlying belief systems; the text contains messages containing keywords, images and other thematic reinforcements of specific facts or judgements. The receiver’s thinking is guided by social context and may or may not reflect the thinking of communicator or text. ‘Culture’ is the stock of commonly invoked words and images that reflect the common discourse or thinking of a group. These framing concepts are used as organizing principles in the analysis, and key differences between the programmes found in Australia, Canada and the United Kingdom are summarized in Table V .

Through analysing policy documents for each country and interviewing key informants, Garvin and Eyles found a different narrative embedded in each national policy. Social, political, cultural and historical contexts within which policy making takes place frame the problem and constrain and limit both problem definition and potential policy making solutions. The findings are summarized in Table V and may provide important information for readers to consider when interpreting the relevance of particular findings in the synthesis to their own context.

It was possible to use the Health Belief Model to provide a coherent synthesis framework for most identified studies. This was used to a greater or lesser extent to structure study design and/or analysis by four included studies. One study, due to a different research focus, was not amenable to this synthesis structure. Most of the included studies essentially wanted to understand and describe attitudes, opinions and practices about tanning, sun/UV safety and skin cancer. By contrast, Garvin and Eyles use framing and narrative to examine differences in public health policies about skin cancer prevention in Australia, Canada and the United Kingdom [ 22 ]. It has been suggested that the contribution of a study report to a synthesis can be used as an indicator of its quality [ 5 , 28 ]. In this instance, however, the study report by Garvin and Eyles produced a sophisticated and well-developed policy analysis which was rated highly by the reviewers and was not amenable to synthesis precisely because of its unique perspective and method.

The review and synthesis of qualitative research is necessarily an interpretive process, and this synthesis remains the work of two researchers. Other interpretations of the findings are possible, and likely, with the use of alternative conceptual frameworks to aid synthesis. We chose to use the Health Belief Model because of its familiarity in health promotion work, its use in four of the included studies and its relevance and amenability to our research questions. It may also be possible and revealing, however, to assess the findings of the studies in relation to nation-specific frames and narratives [ 22 ] or to explore accounts of tanning behaviour in terms of Foucault's disciplinary gaze [ 9 ]. We did not pursue the latter, as such an analysis seemed likely to provide support for, or critique of, this ‘concept’ in relation to risk assessment and behaviour described in the included studies. In addition, we wanted to provide findings translatable into public health recommendations as required by our commissioner. It is also likely to relate only to selected, focussed study findings in each study report, rather than the broad scope offered by the Health Belief Model. We remain aware, however, that the Health Belief Model is not without criticism, particularly in relation to its reliance on rational understandings of human behaviour. Indeed, even within those included studies that used it, one augmented it as using Social Cognitive Theory [ 4 ]. As a framework for synthesis, however, it provided a coherent and useful framework to draw together the findings across a number of different studies and our inclusion of a paper about framing and narrative provides additional cultural context in different Anglophone countries. We did not identify evidence of changing attitudes towards tanned skin, although the papers spanned 15 years. It may be that research done among different communities or more recent studies in the same communities would identify other concerns.

Quality appraisal for qualitative research remains a vexed issue [ 29 , 30 ]. There are no universally accepted indicators of quality in qualitative research and different traditions and expectations of research procedures and reports are seen within and between academic disciplines. Given this lack of consensus, there are also no agreed protocols between researchers, reviewers and editors about the necessary nature and level of methodological detail about a study that should be reported. Limited word counts may also mean that details of data collection and analysis are left out in order to preserve space to report findings. It is often unclear whether potential deficiencies are in the reporting or the actual conduct of the research, and it is anyway unclear what if anything should be considered a ‘fatal flaw’ that would render findings highly suspect or even invalid. A further unknown is how any quality appraisal should influence either the conduct or the use of systematic reviews of qualitative research.

It remains unclear how to ‘weigh’ synthesized findings. Unlike reviews and syntheses of quantitative data, it is not necessarily appropriate to regard the frequency of identifying a finding as conferring cumulative weight or greater generalizability or robustness. Findings reported in a single study may be found particularly insightful or pertinent, whilst findings common to several study reports may be less useful or applicable.

Information campaigns to prevent the first occurrence of skin cancer may be enhanced by taking into consideration public understandings about it. We identified 16 study reports which addressed this and synthesized the findings of 15 of them using the Health Belief Model as a conceptual framework.

The synthesis suggests that people generally perceive their susceptibility to skin cancer, and its severity, as low. While the benefits of adopting protective behaviours in terms of reducing skin cancer risk are often recognized, these can be offset by the perceived benefits of having a tan and a number of practical and social barriers to adopting safer behaviour in relation to UV exposure. Peers, parents and media messages may act as positive cues to action that encourage safer behaviour, and people have a high sense of self-efficacy in terms of their understandings of skin cancer as both preventable and detectable through personal responsibility for behaviour and self-monitoring. Health education resources aimed at encouraging people to protect themselves against skin cancer will need to address these beliefs to encourage preventative behaviour.

National Institute for Health and Clinical Excellence (NICE).

None declared.

This review is part of a series completed for NICE in the United Kingdom for the purposes of developing guidance. The views expressed here are those of the authors and do not necessarily reflect those of NICE. Thanks to Dr Olalekan Uthman and Dr Dechao Wang at West Midlands HTA Collaboration, University of Birmingham, for screening titles and abstracts. With many thanks to Jo Perry, Jenny Lowe and Lianne Perry for administrative project support and to Dr Rob Anderson for helpful comments.

Providing public information to prevent skin cancer

Search protocol and search strategy for relevant qualitative research.

MEDLINE In Process,

HMIC database.

The following Web sites were also interrogated:

The Evidence for Policy and Practice Information and Coordinating Centre (EPPI Centre) (contains the EPPI Centre database and TRoPHI, the Trials Register of Promoting Health Interventions) http://eppi.ioe.ac.uk/cms/ ,

Association of Public Health Observatories http://www.apho.org.uk ,

Cancer Research UK http://www.cancerresearchuk.org/ and

SunSmart (Victoria) http://www.sunsmart.com.au/ .

Reference lists of papers included in the review were examined to identify additional papers which may be relevant to the research question.

A list of included studies was be sent to the project subject experts for them to identify additional papers which may also be relevant to the research question.

Bibliographic database search strategies.

The general approach was to perform a search which captures all components relevant to the general topic (subject-specific search terms) which was combined with a series of ‘methodological filters’ focussing on specific sub-types of literature. Limits for date (1990 onwards) and language (English) were also applied.

The key concepts of the search question are ‘skin cancer and its possible causes’ and ‘methods of primary prevention’.

The subject-specific search terms (parent strategy) were as follows: (MEDLINE strategy presented which was adapted to other databases).

skin cancer.mp.,

exp skin neoplasms/,

non melanoma.mp.,

malignant melanoma.mp.,

exp melanoma/,

basal cell carcinoma.mp.,

squamous cell carcinoma.mp.,

exp carcinoma basal cell/,

exp carcinoma squamous cell/,

(sunburn or sun bed$ or sunbed$ or sunlamp$ or sun lamp$ or tanning or sun tan$ or suntan$).mp.,

(sun expose or sun exposure).mp.,

ultraviolet rays/,

(ultraviolet radiation or ultraviolet rays or ultraviolet exposure or uv rays or uv radiation or uv expos$).mp.,

(prevent or prevents or prevention).mp.,

exp primary prevention/,

health education.mp.,

health education/,

health promotion.mp.,

exp health promotion/,

exp public health/,

public health.mp.,

exp preventive medicine/,

campaign$.mp.,

exp mass media/,

program$.mp.,

pamphlet$.mp.,

publication$.mp.,

leaflet$.mp.,

pamphlets/or publications/,

internet/or internet.mp.),

computer communication networks/,

cellular phone/,

mobile phone$.mp.,

or/17–37 and

Searches to target qualitative studies were performed in the databases mentioned under ‘Primary studies’ above, with the exception of the Cochrane Library. The above-mentioned parent strategy was run and combined with the following terms:(where 39 is the combination of population and intervention above).

1 qualitative research/,

2 [(focus or discussion) adj group].tw.,

3 [(field or case) adj (stud$ or research)].tw.,

4 (interview$ or qualitative).tw.,

5 1, 2, 3 or 4 and

6 5 and 39,

From the pool of studies retrieved, further targeted searches were done (using Reference Manager) on the interventions identified for inclusion in the effectiveness review.

Documentation.

The search process was documented here (databases searched, date searched, timespan searched and results of individual searches) to ensure that it is transparent and reproducible.

The search results were saved and also stored in a Reference Manager database.

Full paper checklist for review 2: qualitative research

OECD, Organisation for Economic Cooperation and Development.

UD, User defined field.

The list provided with the title and abstract screening checklist also applies here.

If a study meets all inclusion criteria except that it is unclear if the mixed population and/or intervention can be disaggregated, the study will be provisionally included and further assessed.

If a study meets all inclusion criteria except that information is unclear for one or more criteria, the study will be provisionally included and further information obtained.

Including, but not limited to, observational methods, interviews and focus groups as methods of data collection and grounded theory, thematic analysis, hermeneutic phenomenological analysis, discourse analysis, etc. as methods of analysis.

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• bibliographic databases
• new zealand
• self efficacy
• sunscreening agents
• health education
• skin cancer
• health-related beliefs
• skin cancer prevention

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