Exercise and nutrition to improve cancer Treatment-Related outcomes (ENICTO).

Chemotherapy treatment-related side-effects are common and increase the risk of suboptimal outcomes. Exercise interventions during cancer treatment improve self-reported physical functioning, fatigue, anxiety, and depression, but it is unclear whether these interventions improve important clinical outcomes, such as chemotherapy relative dose intensity (RDI). The National Cancer Institute funded the Exercise and Nutrition to Improve Cancer Treatment-Related Outcomes (ENICTO) Consortium, to address this knowledge gap. This paper describes the mechanisms hypothesized to underpin intervention effects on clinically-relevant treatment outcomes, briefly outlines each project's distinct research aims, summarizes the scope and organizational structure of ENICTO, and provides an overview of the integrated common data elements used to pursue research questions collectively. In addition, the paper includes a description of consortium-wide activities and broader research community opportunities for collaborative research. Findings from the ENICTO Consortium have the potential to accelerate a paradigm shift in oncology care such that cancer patients could receive exercise and nutrition programming as the standard of care in tandem with chemotherapy to improve RDI for a curative outcome.

Sun protection behavior: health impact, prevalence, correlates and interventions.

Sun protection behavior can reduce skin cancer risk. This paper provides an overview of skin cancer risk and the complex behavioral options for sun protection, along with a narrative review of research on determinants of, and interventions to promote, sun protection. Gaps and opportunities for future research are also outlined. Evidence supports the effectiveness of sunscreen use, ultraviolet (UV) protection clothing, and shade seeking. However, these behaviors are complex and are often performed in ways that are inadequate for sun protection. Most research examining and targeting determinants of sun protection behavior has focused on sunscreen use, to the exclusion of other strategies, and has largely ignored the complexity of even sunscreen use. Most research and interventions are theory- driven, drawing on social cognitive constructs, but also considering self and social identity and emotion. Multilevel perspectives considering context, environment, policies, and other structural contexts have also been applied to sun protection behavior, but there is a need to combine psychological constructs with factors at other levels to optimize predictive models and intervention effectiveness. Effective sun protection effectively involves complex behaviors and perceived and actual tradeoffs that should be considered, in combination with multilevel determinants, in research predicting and promoting sun safety.

Visual Aids for Sunscreen Application: A mixed methods study.

BACKGROUND: Consumers routinely underapply sunscreen, and this may be because they misinterpret application quantity directions on sunscreen labels. U.S. labels use ambiguous terms such as "apply generously" to communicate application quantity. Visual aids may be helpful to consumers to determine proper application quantity. PURPOSE: To examine sunscreen application practices and sunscreen quantity visual aid preferences. METHODS: Sets of five GIFs and five static images were created corresponding to five quantities of sunscreen. Participants extracted their typical-use sunscreen quantity from a pre-measured tube and answered questions about their estimation process and use of labeled instructions. Participants then identified their typical-use sunscreen quantity in response to three stimuli: teaspoons, images, and GIFs and reported their preferred format. RESULTS: No participants reported using the label directions for application quantity to inform their sunscreen use. The GIF-based visual aid for sunscreen application quantity (44%) was preferred over image-based (40%) or teaspoon-based (16%) versions (p = .0249). Addition of a GIF demonstration to clarify application quantity was reported as highly helpful. CONCLUSION: Consumers have difficulty determining the appropriate quantity of sunscreen to use and labeling does not influence their application quantity. A QR code incorporating an image or GIF demonstration of proper sunscreen quantity could be useful to sunscreen consumers.

Rethinking physical activity assessment in cancer survivors: a multi-component approach using NHANES data.

PURPOSE: To confirm that a multi-component physical activity index (PAI), with physical activity (PA)-related behaviors and performance measures, enhances PA assessment for adults with cancer history ("survivors") vs. for the general population for key health variables. METHODS: Data from 2011 to 2014 NHANES were analyzed (n = 9620 adults, including 866 survivors). We generated PAI scores by calculating subscales for activity-related behaviors (i.e., moderate-to-vigorous PA and TV viewing hours/sedentary time) (n/8) and performance (i.e., cardiorespiratory fitness and muscle strength) (n/8), then combined for an overall PAI score (n/16 points). Dependent variables (self-reported health, multimorbidity, and functional limitations) were dichotomized and tested with logistic regression to estimate associations with PAI variables. RESULTS: Survivors obtaining 22.5 + MET hours/week of PA were >5× more likely to report excellent health than non-exercisers (OR = 5.5, 95% CI 3.27-9.28). We observed a general decrease in likelihood of multimorbidity and functional limitations with increasing PA. Models with the combined score showed that higher PAI scores had larger positive associations with all three for all adults. Survivors with higher PAI scores were >30% more likely to report excellent self-rated health (OR = 1.3, 95% CI 1.2-1.4) and 20% less likely to report multimorbidity and functional limitations compared to survivors with lower PAI scores, considering covariates. CONCLUSIONS: Greater PA-related behavior and performance was beneficial for adults irrespective of cancer history. However, using a combined score elucidates unique needs and benefits for survivors vs. for general population. IMPLICATIONS FOR CANCER SURVIVORS: Using a multi-component approach to PA assessment could help in developing validated tools to plan exercise programs and interventions for survivors.

Perceived Usefulness and Recall of Sunscreen Label Information by Consumers.

Importance: In February 2019, the US Food and Drug Administration issued a proposed rule (84 FR 6204), an amendment to the Sunscreen Innovation Act of 2014, that would require listing active ingredients on the principal display panel of sunscreens to allow consumers to "more readily compare products and either select or avoid a given product accordingly." Objective: To understand consumers' perceived importance of active ingredients in sunscreen and their ability to recall these ingredients when comparing, avoiding, or selecting sunscreen products. Design, Setting, and Participants: In this qualitative study, participants were recruited from Fors Marsh Group and User Works, Inc consumer panels and interviewed in person in November and December 2019. Eligible participants were 18 years or older, reported sunscreen use in the past 12 months, and were residents of the Washington, DC, area. After viewing 2 mock sunscreen labels (1 that meets current US Food and Drug Administration requirements and 1 designed to meet proposed requirements), participants were asked questions to assess their perceived importance of active ingredients in sunscreen products, whether they could recall any of the active ingredients on the labels, and whether they typically looked for active ingredients on a sunscreen label. Main Outcomes and Measures: The main outcomes were the sunscreen label information used by participants to select a sunscreen and their ability to recall the active ingredients after viewing 2 mock sunscreen labels. Results: The mean (SD) age of the 47 participants was 42.8 (13.6) years, 32 (68%) were women, and 40 (85%) had a bachelor's or graduate degree. Of the total, 13 (28%) participants stated that sunscreen ingredients influenced their sunscreen selection, but only 5 (11%) said it was the most important information. Instead, 34 (72%) participants stated that the sun protection factor rating was the most important information. After viewing the mock sunscreen labels, only 5 (11%) participants recalled any of the active ingredients, although 10 (21%) reported typically looking at active ingredients when choosing a sunscreen. Conclusions and Relevance: This qualitative study investigated the US Food and Drug Administration's proposed new rule requiring that active ingredients be listed on the front of sunscreen labels to facilitate product comparison for consumers. However, active ingredients were not reported to be a primary reason for consumers' sunscreen selection. Recall of active ingredients was low, and few consumers reported typically looking at the active ingredients, which were more commonly used to avoid ingredients rather than to select a sunscreen. Therefore, listing active ingredients on the front label alone may not have the intended usefulness for consumers.

The Context of Sunburn Among U.S. Adults: Common Activities and Sun Protection Behaviors.

INTRODUCTION: Sunburn increases skin cancer risk and is common among U.S. adults. However, little is known about the contexts in which sunburns often occur. The purpose of this study is to examine the contextual factors surrounding sunburns among U.S. adults. METHODS: Cross-sectional data from a 2018 online panel survey were analyzed. A total of 4,088 panel members were recruited by mail using probability-based, random sampling by address. Respondents were asked about their most recent sunburn, and analyses were limited to those who remembered their most recent sunburn (N=3,106). Data were weighted to match the U.S. Current Population Survey proportions; analyses were conducted in 2018 and 2019. RESULTS: Participants' age ranged from 18 to 93 years. About half (50.8%) were women, and most (82.3%) were non-Hispanic White adults. Swimming or spending time in water (32.5%), working outside at home (26.2%), traveling/vacationing (20.7%), and engaging in nonswimming physical activity (14.2%) were the most frequently reported activities. Using sunscreen on the face, neck, and chest (38.8%) and on the body (19.9%) and wearing sunglasses (34.2%) were the most frequently reported sun safety behaviors. Wearing clothes to the ankles (6.6%) and a long-sleeved shirt (4.5%) were least frequently reported. CONCLUSIONS: This study provides new information about the contexts in which adult sunburns often occur, especially about contexts unrelated to intentional tanning, which was relatively infrequent. The results suggest the need to promote multiple forms of sun protection tailored to specific outdoor activities and develop innovative solutions for outdoor physical and aquatic activities, which present unique sun safety challenges.

Standards-based physical education in schools: The role of state laws.

Purpose: Examine the association of state physical education (PE) laws (https://class.cancer.gov) with school policies addressing motor skill development, physical activity (PA) participation, and health-enhancing physical fitness (https://www.cdc.gov/healthyyouth/data/shpps/data.htm). Methods: National school-level data on PE standards were obtained from the 2014 School Health Policies and Practices Study (SHPPS) of US schools for analytical samples of 408-410 schools in 43 states. These data were linked to Classification of Laws Associated with School Students (CLASS) data, which reflect the strength of state-PE curriculum laws and the associated state PE curriculum standards. Logistic regressions and generalized linear models with a complementary log-log link examined associations between state law and school-level standards. Results: Compared to having no state law, weak law (OR: 5.07, 95% CI: 1.02-25.27) or strong law (OR: 2.96, 95% CI: 1.04-8.37) was associated with higher odds of school PE standards addressing motor skill development, while only strong state law was associated with higher prevalence of addressing achievement and maintenance of physical fitness (coefficient: 0.63, 95% CI: 0.12, 1.14). State laws were not associated with addressing PA participation. Conclusions: Schools were more likely to address motor skills and physical fitness development when states had strong PE laws.

Associations between ultraviolet radiation, tree cover and adolescent sunburns.

BACKGROUND: Sunburn is the strongest risk factor for melanoma and non-melanoma skin cancers. Adolescent sunburns are related to higher risk of developing melanoma later in life. Little is known about the association of sunburns and shade, particularly tree cover, around adolescent homes and schools. This linkage study assessed associations of adolescent self-reported sunburns with ambient ultraviolet radiation (UV) and tree cover. METHODS: We analyzed a U.S. national sample of parent-child dyads (n = 1333) from the 2014 Family Life, Activity, Sun, Health, and Eating (FLASHE) study conducted by the National Cancer Institute. The outcome was adolescent sunburns reported for the previous 12 months. GIS buffers around geocoded home and school addresses were used to summarize UV and tree cover. A sensitivity analysis assessed different UV measures and tree cover buffer distances. Logistic regression models estimated the adjusted odds of any sunburns for five models: (1) no environmental variables; (2) spatial variables of latitude and longitude; (3) UV; (4) tree cover; and, (5) a combined model with UV and tree cover. Covariates included common sunburn-related items such as sun protective behaviors, socio-demographics, and latitude. Model residuals were assessed for spatial dependency and clustering. RESULTS: Overall, 44% of adolescents reported any sunburns in the previous 12 months. For the bivariate associations, lower categories of UV were associated with any reported sunburns (p-trend = 0.002). Home tree cover was not associated with any reported sunburns (p-trend = 0.08), whereas schools with lower categories of tree cover were associated with sunburns (p-trend = 0.008). The adjusted odds of any sunburns by UV tertiles, as a linear tread, was 0.89 (0.76-1.05) (p = 0.17); school tree cover was: 0.91 (0.78-1.07) (p = 0.25). Neither UV nor tree cover, in a combined model, were significant. Sensitivity analyses resulted in the optimal buffer size of 200 m for summarizing tree cover. Spatial dependence of residuals was not significant and clustering was significant for about 6% or less of the sample in each model. CONCLUSIONS: We did not find significant relationships between UV or tree cover and adolescent sunburns, when adjusted by sunburn-related covariates. Better contextual data about where sunburns occurred is needed to identify environmental correlates of sunburn.

Health Behaviors of Cancer Survivors and Population Controls From the National Health Interview Survey (2005-2015).

BACKGROUND: Population-based data from the National Health Interview Survey were examined to provide estimates of a wide range of health behaviors in cancer survivors (ie, physical activity, sun protection, alcohol use, cigarette and e-cigarette use, sleep, and diet) and trends over time. METHODS: Data were collected from 92 257 participants across 3 waves of the National Health Interview Survey. A total of 8050 participants reported having had cancer (2428 in 2005, 2333 in 2010, 3289 in 2015). Weighted and adjusted odds ratios (OR) between cancer survivors and controls were calculated using logistic and multivariable regressions in SPSS, and trend analyses from 2005 to 2015 were conducted. All statistical tests are 2-sided. RESULTS: After adjusting for demographics (2005-2015), cancer survivors, compared with controls, were more likely to wear sunscreen (OR = 1.41, 95% confidence interval [CI] = 1.32 to 1.51) and protect their skin (P < .001) and were less likely to tan indoors (OR = 0.81, 95% CI = 0.69 to 0.95), but reported less sleep (OR = 0.91, 95% CI = 0.85 to 0.98). In adjusted models, no differences were found for physical activity, sunburns, alcohol use, smoking, e-cigarette use, and diet. Smoking rates for cancer survivors decreased from 2005 to 2015 (P < .001) and physical activity increased (P = .02), but physical activity was not statistically significant after adjusting for multiple comparisons. All other health behavior rates for cancer survivors were unchanged from 2005 to 2015 (P > .14). CONCLUSION: After adjusting for covariates, cancer survivors exhibited healthier sun protection, but not sleep behaviors, compared with controls. Cancer survivors (and controls) exhibited decreased smoking rates over time. These results may inform interventions focused on improving cancer control and prevention of other chronic conditions among cancer survivors.

The harmonizing effect of Smart Snacks on the association between state snack laws and high school students' fruit and vegetable consumption, United States-2005-2017.

Despite national guidelines recommending daily fruit and vegetable (FV) consumption, intake of FV among adolescents is low. Over the past 10-15 years, state and federal laws have reduced the availability of junk foods in schools. This study examined the association between state snack laws and high school (HS) student FV consumption. The overall sample included 99,785 HS students (outcome samples ranged from 96,209-97,328) included in the Youth Risk Behavior Survey (YRBS). National Cancer Institute Classification of Laws Associated with School Students' data for 2004-2016 were lagged on to 2005-2017 YRBS data. Separate analyses examined the state law-youth FV consumption relationship pre- and post-federal Smart Snacks standards (effective school year 2014-2015). Analyses were conducted between 2018 and 2020. Overall, state laws were associated with any vegetable, salad, and other vegetable consumption. The relationship between state laws and vegetable consumption primarily occurred pre-Smart Snacks. Pre-Smart Snacks, state laws were associated with higher odds of youth consumption of any vegetable, salad, carrots, and other vegetables (all compared to students in states without snack laws). The only association post-Smart Snacks was between strong state laws and salads. This study illustrates the important role that standards restricting the availability of junk foods in schools can have on increasing student vegetable consumption. Given current efforts to roll-back federal school meal standards, findings from this study illustrate how federal standards harmonized the patchwork of state laws that existed prior to Smart Snacks and the important role that consistent national standards can play in supporting student consumption of vegetables.

Cross-sectional Association between Walking and Sunburn: A Potential Trade-off between Cancer Prevention and Risk Factors.

BACKGROUND: The positive association between physical activity and sunburn is a health behavior trade-off between the health benefits of physical activity and increased risk of skin cancer. PURPOSE: We assessed walking, which is a common source of physical activity, and the prevalence of sunburn. METHODS: This research used the 2015 National Health Interview Survey of adults (N = 26,632), age ≥ 18 years. We defined four exclusive categories of walking: (a) those who reported not walking; (b) only transportation (to get some place, such as work, a store, or public transit stop); (c) only leisure (such as for fun, relaxation, or exercise); and (d) both categories. We estimated the adjusted prevalence of sunburn by walking category and separately for walking duration; we stratified by gender and sun sensitivity. RESULTS: The adjusted sunburn prevalence was not different between walking categories for women, but it was for men. Specifically, prevalence was lower for men who reported not walking, 34.1% (95% confidence interval [CI]: 32.2%-36.1%) compared to 38.8% (95% CI: 36.5%-41.2%) who walked for both purposes (p = .003). Walking duration was not associated with sunburn prevalence. CONCLUSION: We could not determine whether sunburn occurred during walking trips because the questions were not asked as such. However, the results suggest that walking, unlike leisure-time physical activity (such as exercise, sports, or physically active hobbies), may not generally be associated with sunburn, except for the higher sunburn prevalence for men who walked for both leisure and transportation purposes.

Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary Roundtable.

PURPOSE: The number of cancer survivors worldwide is growing, with over 15.5 million cancer survivors in the United States alone-a figure expected to double in the coming decades. Cancer survivors face unique health challenges as a result of their cancer diagnosis and the impact of treatments on their physical and mental well-being. For example, cancer survivors often experience declines in physical functioning and quality of life while facing an increased risk of cancer recurrence and all-cause mortality compared with persons without cancer. The 2010 American College of Sports Medicine Roundtable was among the first reports to conclude that cancer survivors could safely engage in enough exercise training to improve physical fitness and restore physical functioning, enhance quality of life, and mitigate cancer-related fatigue. METHODS: A second Roundtable was convened in 2018 to advance exercise recommendations beyond public health guidelines and toward prescriptive programs specific to cancer type, treatments, and/or outcomes. RESULTS: Overall findings retained the conclusions that exercise training and testing were generally safe for cancer survivors and that every survivor should "avoid inactivity." Enough evidence was available to conclude that specific doses of aerobic, combined aerobic plus resistance training, and/or resistance training could improve common cancer-related health outcomes, including anxiety, depressive symptoms, fatigue, physical functioning, and health-related quality of life. Implications for other outcomes, such as peripheral neuropathy and cognitive functioning, remain uncertain. CONCLUSIONS: The proposed recommendations should serve as a guide for the fitness and health care professional working with cancer survivors. More research is needed to fill remaining gaps in knowledge to better serve cancer survivors, as well as fitness and health care professionals, to improve clinical practice.

Walking and Sun Protective Behaviors: Cross-Sectional Associations of Beneficial Health Factors.

Sun protective behaviors and physical activity have the potential to reduce cancer risk. Walking is the most common type of physical activity in the United States, but it is unclear whether sun protective behaviors differ by categories of walking, such as leisure versus transportation walking. We examined whether sun protective behaviors varied by category or duration of walking in the 2015 National Health Interview Survey (N = 26,632), age ≥ 18 years. We used logistic regression to estimate sunscreen use, sun avoidance, and sun protective clothing use by four categories of walking (no reported walking, transportation only, leisure only, or walking for both) and separately for walking duration for the general population and sun-sensitive individuals. Prevalence of sunscreen use varied across walking categories and the odds of use were higher with longer walking duration for transportation and leisure compared to those who reported no walking. Sun avoidance varied across walking categories and the odds of avoidance were lower with longer duration leisure but not transportation walking. Sun protective clothing varied across walking categories and the odds of use were higher for longer duration transportation, but not leisure walking. Data on the concurrence of walking and sun protection is needed to further understand the relationship between these health behaviors. By examining leisure and transportation walking, we found variations in sun protective behaviors that may provide important insight into strategies to increase sun protection while promoting physical activity.

School contextual correlates of physical activity among a national adolescent sample.

Schools are an important context to promote adolescent physical activity (PA). However, following ecologic frameworks, little is known about the influence of multiple school contextual levels - environment and policy - on adolescent PA. This study aimed to examine associations of school neighborhood environment factors and state laws with PA, and the moderating effects of school neighborhood socioeconomic status (SES) on these associations. Analyses used cross-sectional data from a national sample of middle (n = 387) and high (n = 591) school adolescents from the Family Life, Activity, Sun, Health, and Eating study conducted in 2014. Outcomes included self-report school-time PA and active transport to/from school (ATS), and estimated minutes/week of school-related moderate-to-vigorous PA (MVPA) and total MVPA. Separate regression models for middle and high school respondents examined state laws (school PA or physical education (PE) time requirements) and school neighborhood factors (density, age, and commute times), and their interactions with school neighborhood SES, in relation to each PA outcome, adjusting for socio-demographic and psychosocial factors. The high school models showed strong PE laws (B[SE]: 0.3[0.1], p = 0.02) and any PA law (B[SE]: 0.3[0.1], p = 0.0003) were related to higher school-time PA, and shorter school neighborhood commute times were related to lower ATS (OR [95% CI]: 0.4 [0.2-0.7]). We found similar associations with estimated school-related MVPA. The middle school models showed no significant state law or school neighborhood main effects. Interactions with school neighborhood SES were not significant. Our findings provide further support for state laws to promote PA in school regardless of school neighborhood SES.

Decision Tree Model vs Traditional Measures to Identify Patterns of Sun-Protective Behaviors and Sun Sensitivity Associated With Sunburn.

Importance: Understanding patterns of sun-protective behaviors and their association with sunburn can provide important insight into measurement approaches and intervention targets. Objective: To assess whether decision-based modeling can be used to identify patterns of sun-protective behaviors associated with the likelihood of sunburn and to compare the predictive value of this method with traditional (ie, composite score) measurement approaches. Design, Setting, and Participants: This cross-sectional study used a nationally representative sample of 31 162 US adults from the 2015 National Health Interview Survey, consisting of household interviews conducted in person and completed by telephone when necessary. Participants included civilian noninstitutionalized US adults. Data were collected from January 1 through December 31, 2015. Main Outcomes and Measures: The associations among sun sensitivity, multiple sun-protective behaviors (ie, using sunscreen, seeking shade, wearing a hat, and wearing protective clothing), and sunburn were examined using a χ2 automatic interaction detection method for decision tree analysis. Results were compared with a composite score approach. Results: In our study population of 28 558 respondents with complete data (54.1% women; mean [SD] age, 49.0 [18.0] years), 20 patterns of sun protection were identified. Among 15 992 sun-sensitive individuals, those who used only sunscreen had the highest likelihood of sunburn (62.4%). The group with the lowest likelihood of sunburn did not report using sunscreen but engaged in the other 3 protective behaviors (24.3% likelihood of sunburn). Among 12 566 non-sun-sensitive individuals, those who engaged in all 4 protective behaviors had the lowest likelihood of sunburn (6.6%). The highest likelihood of sunburn was among those who only reported sunscreen use (26.2%). The decision tree model and the composite score approach correctly classified a similar number of cases; however, the decision tree model was superior in classifying cases with sunburn (44.3% correctly classified in the decision tree vs 25.9% with the composite score). Conclusions and Relevance: This innovative application of a decision tree analytic approach demonstrates the interactive and sometimes counterintuitive effects of multiple sun-protective behaviors on likelihood of sunburn. These data show where traditional measurement approaches of behavior may fall short and highlight the importance of linking behavior to a clinically relevant outcome. Given the scope of those affected and enormous associated health care costs, improving efforts in skin cancer prevention has the potential for a significant effect on public health.

Prevalence of Sun Protection Use and Sunburn and Association of Demographic and Behaviorial Characteristics With Sunburn Among US Adults.

Importance: Monitoring sun protection and sunburn over time at the population level can provide valuable information about progress toward skin cancer prevention goals and inform future intervention efforts. Objective: To examine the prevalence of sun protection use (shade, sunscreen, and clothing) and sunburn and the association between sunburn and individual characteristics and health behaviors in the US population. Design, Setting, and Participants: In this cross-sectional study using a nationally representative sample of 31 162 US adults from the 2015 National Health Interview Survey-Cancer Control Supplement, household interviews of civilian, noninstitutionalized US adults were conducted throughout 2015 in person and completed on the telephone when necessary. Data analysis was performed from August 16, 2016, to September 6, 2017. Main Outcomes and Measures: The prevalence of sunburn and use of sun protection and their association with demographic characteristics, sun sensitivity, and health-related behaviors and conditions using multivariable logistic regression modeling. Results: A total of 31 162 respondents (mean [SD] age, 47.0 [0.36] years; 13 932 male [44.7%] and 17 230 female [55.3%]) were included in the analyses, with 34.2% experiencing sunburn in 2015. Sunburn prevalence was higher among younger age groups (51.2% in adults 18-29 years old; 95% CI, 48.8%-53.7%), non-Hispanic white individuals (42.5%; 95% CI, 41.2%-43.9%), and those with sun-sensitive skin (50.2%). However, sunburn was also prevalent among black (13.2%; 95% CI, 11.6%-15.1%) and Hispanic (29.7%; 95% CI, 27.6%-31.9%) individuals, demographic groups that are often considered to be at low risk of skin cancer. The most frequent sun protection behaviors were staying in the shade (37.1%; 95% CI, 36.3%-38.0%) and using sunscreen (31.5%; 95% CI, 30.7%-32.3%) followed by wearing long clothing to the ankles (28.4%; 95% CI, 27.6-29.1). Sun avoidance behaviors (seeking shade and not going in the sun) were significantly (39.5% vs 35.1%; P < .001) associated with a lower prevalence of sunburn. Those who used self-applied sunless tanning products (45.0% of users vs 36.1% of nonusers; P < .001), those who engaged in aerobic activity (37.9% of aerobic exercisers vs 32.8% of non-aerobic exercisers; P < .001), binge drinkers (45.1% of binge drinkers vs 35.0% of non-binge drinkers; P < .001), and overweight or obese individuals (37.9% of overweight or obese individuals vs 34.4% of non-overweight or obese individuals; P < .001) were more likely to experience sunburn compared with the respective comparison groups. Conclusions and Relevance: Sun sensitivity was significantly associated with a higher sunburn prevalence, independent of race/ethnicity, suggesting a need to consider sun sensitivity when identifying target demographic groups for sun safety interventions. Efforts to improve vigilance and consistency with use of sun protection are needed. In addition, those who engage in physical activity, use sunless tanners, or use sunscreen for tanning purposes may require additional intervention strategies to address the unique barriers they face in staying adequately protected.

Skin cancer interventions across the cancer control continuum: A review of experimental evidence (1/1/2000-6/30/2015) and future research directions.

While the general efficacy of skin cancer interventions have been reviewed, employing the cancer control continuum would be useful to identify research gaps at specific cancer control points. We characterized the intervention evidence base for specific behavioral targets (e.g., tanning, sun protection, screening) and clinically related targets (e.g., sunburn, skin exams, cancers) at each point in the cancer control continuum. The review included articles published from 1/1/2000-6/30/15 that had an experimental design and targeted behavioral intervention in skin cancer (e.g., specific behaviors or clinically related targets). The search yielded 86 articles, including seven dissemination studies. Of the 79 non-dissemination studies, 57 exclusively targeted primary prevention behaviors, five exclusively targeted screening, 10 targeted both detection and prevention, and eight addressed cancer survivorship. Among prevention studies (n=67), 29 (43%) targeted children and 38 (57%) targeted adults. Of the 15 screening studies, nine targeted high-risk groups (e.g., men aged ≥50 years) and six targeted the general population. Although research has focused on skin cancer prevention, empirically validated interventions are still needed for youth engaged in indoor tanning and for behavioral interventions to pursue change in clinically relevant targets. Research must also address detection among those at highest risk for skin cancer, amelioration of emotional distress attendant to diagnosis and treatment, and survivorship concerns. We discuss essential qualities and opportunities for intervention development and translational research to inform the field.

Interdisciplinary Perspectives on Sun Safety.

Overexposure to the sun is associated with an increased risk of melanoma and nonmelanoma skin cancer, but indications of improvements in sun protection behavior are poor. Attempts to identify emerging themes in skin cancer control have largely been driven by groups of experts from a single field. In December 2016, 19 experts from various disciplines convened for Interdisciplinary Perspectives on Skin Cancer, a 2-day meeting hosted by the National Academy of Sciences. The group discussed knowledge gaps, perspectives on sun exposure, implications for skin cancer risk and other health outcomes, and new directions. Five themes emerged from the discussion: (1) The definition of risk must be expanded, and categories for skin physiology must be refined to incorporate population diversities. (2) Risky sun exposure often co-occurs with other health-related behaviors. (3) Messages must be nuanced to target at-risk populations. (4) Persons at risk for tanning disorder must be recognized and treated. (5) Sun safety interventions must be scalable. Efficient use of technologies will be required to sharpen messages to specific populations and to integrate them within multilevel interventions. Further interdisciplinary research should address these emerging themes to build effective and sustainable approaches to large-scale behavior change.

Skin cancer interventions across the cancer control continuum: Review of technology, environment, and theory.

The National Cancer Institute's Skin Cancer Intervention across the Cancer Control Continuum model was developed to summarize research and identify gaps concerning skin cancer interventions. We conducted a mapping review to characterize whether behavioral interventions addressing skin cancer prevention and control from 2000 to 2015 included (1) technology, (2) environmental manipulations (policy and/or built environment), and (3) a theoretical basis. We included 86 studies with a randomized controlled or quasi-experimental design that targeted behavioral intervention in skin cancer for children and/or adults; seven of these were dissemination or implementation studies. Of the interventions described in the remaining 79 articles, 57 promoted only prevention behaviors (e.g., ultraviolet radiation protection), five promoted only detection (e.g., skin examinations), 10 promoted both prevention and detection, and seven focused on survivorship. Of the 79 non-dissemination studies, two-thirds used some type of technology (n=52; 65.8%). Technology specific to skin cancer was infrequently used: UVR photography was used in 15.2% of studies (n=12), reflectance spectroscopy was used in 12.7% (n=10), and dermatoscopes (n=1) and dosimeters (n=2) were each used in less than 3%. Ten studies (12.7%) targeted the built environment. Fifty-two (65.8%) of the studies included theory-based interventions. The most common theories were Social Cognitive Theory (n=20; 25.3%), Health Belief Model (n=17; 21.5%), and the Theory of Planned Behavior/Reasoned Action (n=12; 15.2%). Results suggest that skin cancer specific technology and environmental manipulations are underutilized in skin cancer behavioral interventions. We discuss implications of these results for researchers developing skin cancer behavioral interventions.