The more serious they perceived melanoma to be, the more likely they were to take it seriously and to make sure their behaviors aligned with that seriousness.— Rachel Isaksson Vogel, PhD
Long-term survivors of melanoma are more likely than those who have not been diagnosed with the disease to use sunscreen, protective clothing, and other means to limit exposure to the sun, according to a survey of melanoma survivors and controls about ultraviolet radiation exposure and protective measures used in the past year. Still, 19.5% of melanoma survivors reported getting sunburned, 10.4% reported intentionally tanning, and 1.7% reported using a tanning booth or bed. The survey results were published in Cancer Epidemiology, Biomarkers and Prevention.1
The surveyed survivors had been diagnosed an average of 9.6 ± 1 years before the survey, and 85.6% had stage I disease. Both of these factors are important in understanding the results, the study’s lead author, Rachel Isaksson Vogel, PhD, said in an interview with The ASCO Post. Dr. Vogel is Assistant Professor, Department of Obstetrics, Gynecology and Women’s Health, at the University of Minnesota, Minneapolis.
Early vs Late Stage of Disease
Most patients with early-stage melanoma have surgery and no additional treatment. “Because of that, there is this idea that melanoma is just another skin cancer, ” Dr. Vogel said.
The small percentage of melanoma survivors who had been diagnosed with stage II (6.4%), stage III (6.6%), or stage IV (1.4%) disease prevented the researchers from establishing any correlation between later-stage disease and sun exposure behaviors. Dr. Vogel pointed out that although the study involved mostly patients with early-stage disease, “that is the distribution of people who survive melanoma. We generally catch it early, and if not, it is deadly. So, this is a good cross-section of long-term melanoma survivors.”
Taking It Seriously
In focus groups preceding the study, melanoma survivors with more advanced-stage disease reported being “far more vigilant, because they understood how serious it was,” Dr. Vogel said. “That was the biggest factor. It wasn’t age or gender. It was how serious they perceived melanoma to be. The more serious they perceived melanoma to be, the more likely they were to take it seriously and to make sure their behaviors aligned with that seriousness.”
In addition, “some patients with stage I disease who had a family history of melanoma were also more likely to take it seriously because they had seen what could happen,” Dr. Vogel added. “Even if their disease was easy to treat, they may have a family member who died of melanoma or endured more difficult and prolonged treatment.” Further, “if they experience a recurrence or another melanoma, it might be stage II, III, or IV,” Dr. Vogel said
Time Lapse Factor
The survey was conducted in 2015, when the melanoma survivors were on average about 9.6 years out from diagnosis. The time since diagnosis is linked to waning vigilance about sun protection. “Other studies suggest people are really good the first year after diagnosis and that it starts to wane in the first couple of years after that (3 to 5 years if not sooner),” Dr. Vogel stated.
It would be interesting, she proposed, to study sun exposure and protection behaviors among melanoma survivors in the first 3 to 5 years after diagnosis to see if they were similar to those in the current study. Another revealing study, she added, might be “to look at people from the time of diagnosis and follow them forward to see when changes happen and when things started to wane, if they did.”
According to an American Association for Cancer Research (AACR) news release about the study, Dr. Vogel said: “In conversations with individuals diagnosed with melanoma, many survivors expressed a desire ‘just to live their lives,’ playing with their children, exercising, and socializing outdoors.”2
An online feature on the study reported that Dr. Vogel “puts the findings in the glass-half-full category. These survivors are almost 10 years out, and the fact that they are doing better [than the control group] at all is surprising.”3
Sun Protection Behaviors
The study involved 724 individuals, identified through the Minnesota Cancer Surveillance System and diagnosed with invasive cutaneous melanoma between July 2004 and December 2007, and 660 controls randomly selected through the state’s driver’s license list and matched for age and sex. Melanoma survivors were more likely to have a high phenotypic risk score due to having many freckles or moles, having used indoor tanning, and having more lifetime sunburns before their diagnosis.
“Melanoma survivors compared with controls were more likely to report often or always engaging in sun protection behaviors,” the researchers reported. These behaviors included using sunscreen (61.9% vs 38.4%) as well as wearing a shirt with sleeves (77.0% vs 65.9%) and a hat (33.2% vs 22.6%) “Survivors were also more likely to stay in the shade in the summer” (48.1% vs 28.7%), the authors added.
Sun Exposure Behaviors
“Compared with controls, survivors were statistically signiﬁcantly more likely to report optimal exposure behaviors, with the exception of sun exposure on weekend days in the summer,” the researchers reported. Spending 2 or more hours outside in the summer on weekend days was reported by 74.8% of melanoma survivors vs 79.7% of controls. On weekdays, however, fewer members of both groups spent 2 or more hours outside, and the difference was greater (34.3% for melanoma survivors vs 44.4% for controls).
Survivors were less likely to report a sunburn in the past year (19.5% vs 36.5% for controls) and to have intentionally spent time in the sun to get a tan (10.4% vs 23.2%).
Tanning Booth Users
“We found that few melanoma survivors and controls reported indoor tanning in the past year,” the authors wrote. (Using a tanning booth or tanning bed was reported by 1.7% of melanoma survivors and 6.8% of controls.) “This may be explained by the fact that this study population is now older and therefore less likely to use indoor tanning, and prevalence of indoor tanning has declined over time. A small number of survivors still reported engaging in this behavior. This phenomenon has been reported elsewhere and indicates a small proportion of individuals will continue this high-risk behavior despite a melanoma diagnosis.”
In the current study, Dr. Vogel pointed out, “it wasn’t just young women” melanoma survivors who reported using tanning booths. “That was what I was expecting, but it is actually not the case. It was equally young women and middle-aged men.”
Risk and Opportunities for Young Patients
“The young age at diagnosis of melanoma for some suggests ample opportunity to engage in improved sun protection behavior following diagnosis,” the authors noted in the introduction to their study. The study results showed, however, that the oldest melanoma survivors “were more likely to avoid sun exposure on weekend days compared with controls, whereas those 30 to 49 and 50 to 59 years old reported similar sun exposure on weekend days compared with controls.”
Dr. Vogel noted that although melanoma “is prominent in older people, especially older men, there is a number of young people, especially young women, who get melanoma. Among those who are 15 to 29, it is the second most common cancer, behind lymphoma.”
These young patients “who are diagnosed in their 20s are the ones I am most concerned about, because they have potentially another 50 years plus of exposure and could end up with melanoma multiple times,” Dr. Vogel stated. “They have a great opportunity for behavior change to impact their lives.” ■
Disclosure: Dr. Vogel reported no potential conflicts of interest.
2. American Association for Cancer Research: While most melanoma survivors limit sun exposure, some report getting suntans and sunburns. News Release. March 2, 2017. Available at http://www.aacr.org/Newsroom/Pages/News-Release-Detail.aspx?ItemID=1008#.WOU2_HeZOi4. Accessed April 5, 2017.
3. Hobson K: Some melanoma survivors are still getting too much sun exposure. NPR Shots Your Health, March 2, 2017. Available at http://www.npr.org/sections/health-shots/2017/03/02/517967766/some-melanoma-survivors-are-still-getting-too-much-sun-exposure. Accessed April 5, 2017.