Engaging Community Health Workers in Primary Care Practices: Provider Understanding of Roles, Benefits, and Barriers.

Community health workers (CHWs) are increasingly addressing health disparities in primary care settings; however, there is little information about how primary care practitioners (PCPs) interact with CHWs or perceive CHW roles. We examined PCP engagement with CHWs in adult primary care settings. Overall, 55% of 1504 PCPs reported working with CHWs; involvement with CHWs differed by some PCP demographic and practice-related factors. While PCPs perceived CHWs as engaging in most nationally endorsed CHW roles, they identified several barriers to integrating CHWs into care teams. Findings can inform ongoing efforts to advance health equity through integrating CHWs into primary care practices.

Reducing Cancer Risk Through Primary Prevention Activities Among Children: A Demonstration Project.

CONTEXT: Opportunities to reduce the risk of cancer, including cervical, liver, and skin cancer, start early in life. To encourage adoption of primary prevention activities in childhood to reduce cancer risk later in life, Centers for Disease Control and Prevention conducted a demonstration project with 3 National Comprehensive Cancer Control Program (NCCCP) recipients. PROGRAM: Iowa, Northwest Portland Area Indian Health Board (NPAIHB), and Pennsylvania NCCCP recipients implemented evidence-based primary prevention activities for cervical, liver, and skin cancer among children using health care provider education, patient education, and policy development. IMPLEMENTATION: Iowa implemented an announcement approach to improve provider education on human papillomavirus (HPV) vaccination. Pennsylvania focused on patient education for reducing skin cancer risk and both provider and patient education for liver cancer prevention. NPAIHB created a sun safety intervention for tribal organizations, including a policy guide, media materials, and patient education. RESULTS: In Iowa, health care providers taking the announcement approach reported significantly higher mean scores on a posttest compared with a pretest regarding perceptions about HPV vaccination, self-efficacy, and behavioral intentions related to vaccination. Pennsylvania integrated sun safety education and sunscreen dispenser programs as a health and wellness initiative in 8 state parks and the Pennsylvania Department of Conservation and Natural Resources incorporated the program in its Pennsylvania Outdoor Recreation Plan. Pennsylvania also implemented health care provider education on the primary prevention of liver cancer through hepatitis B and hepatitis C screening and hepatitis B vaccination. The NPAIHB skin cancer policy guide was created and distributed for use to all 43 federally recognized tribes of Oregon, Washington, and Idaho served by NPAIHB. DISCUSSION: The identification, dissemination, and implementation of these efforts can serve as best practices for future childhood primary prevention programs. NCCCP recipients and public health professionals can use health care provider education, patient education, and policy development to reduce future risk for cervical, liver, and skin cancer among children.

Melanoma Incidence Rates Among Non-Hispanic American Indian/Alaska Native Individuals, 1999-2019.

Importance: Non-Hispanic American Indian/Alaska Native people have the second highest incidence rate of invasive cutaneous melanoma in the US after non-Hispanic White people. Objective: To examine invasive cutaneous melanoma incidence rates and trends over time among non-Hispanic American Indian/Alaska Native people. Design, Setting, and Participants: This descriptive, observational cross-sectional study used population-based cancer registry data (US Cancer Statistics AI/AN Incidence Analytic Database) linked to the Indian Health Service administrative database to examine incidence rates by age, sex, region, histology, tumor site, stage, and other demographic and clinical characteristics. The study examined trends from 1999 to 2019 time period by age, sex, stage at diagnosis, and region. Non-Hispanic American Indian/Alaska Native people 15 years and older who received a diagnosis of invasive cutaneous melanoma from 1999 to 2019 who were members of federally recognized tribes and resided in Indian Health Service purchased/referred care delivery areas were included in this study to reduce racial misclassification and provide more accurate rates. The data were analyzed in 2022. Exposures: Demographic and clinical characteristics, such as age, sex, geographic region, histology, stage, and tumor site. Main Outcomes and Measures: Invasive cutaneous melanoma incidence rates by age group, sex, region, resident county characteristics (poverty level, rurality, education level, and socioeconomic status), stage at diagnosis, tumor site, and histology. Trends over time by age, sex, region, and stage. Results: From 1999 to 2019, 2151 non-Hispanic American Indian/Alaska Native people (1021 female individuals [47.5%]) received a diagnosis of incident cutaneous melanoma (rate, 10.7 per 100 000; 95% CI, 10.3-11.2). Rates were higher among male than female individuals (13.0 [95% CI, 12.2-13.8] vs 9.2 [95% CI, 8.6-9.8]) and for people 55 years and older (24.2; 95% CI, 22.8-25.7) compared with those aged 15 to 39 years (3.5; 95% CI, 3.2-3.9). Rates were highest for male individuals 55 years and older (34.5; 95% CI, 31.8-37.3) and people living in the Southern Plains (male individuals: 23.8; 95% CI, 21.5-26.2; female individuals: 15.5; 95% CI, 14.0-17.2) and Pacific Coast region (male individuals: 16.5; 95% CI, 14.5-18.7; female individuals: 12.3; 95% CI, 10.9-13.9). Rates increased among female individuals from 1999 to 2019 (average annual percent change [AAPC], 2.5; P < .001); among regional/distant stage tumors (AAPC, 2.5; P = .01) and people 55 years and older (AAPC, 2.8; P = .001). Conclusions and Relevance: The results of this study suggest that additional studies could potentially identify risk factors among non-Hispanic American Indian/Alaska Native people.

Acral lentiginous melanoma incidence by sex, race, ethnicity, and stage in the United States, 2010-2019.

INTRODUCTION: Acral lentiginous melanoma (ALM) is a rare type of melanoma associated with delayed diagnosis and poor survival rates. This study examines ALM incidence rates in comparison to all other melanoma types. METHODS: We used data from the Centers for Disease Control and Prevention's National Program of Cancer Registries and the National Cancer Institute's Surveillance, Epidemiology, and End Results Program, which together cover 99% of the US population. We calculated age-adjusted rates and rate ratios for ALM and all other malignant melanomas by sex, race and ethnicity, stage, and year of diagnosis (2010-2019). RESULTS: ALM incidence rates were significantly lower among non-Hispanic Black persons (1.8 per 1,000,000); non-Hispanic Asian/Pacific Islander (API) persons (1.7 per 1,000,000); and Hispanic Black, American Indian/Alaska Native (AI/AN), and API persons (1.5 per 1,000,000) compared to non-Hispanic White persons (2.3 per 1,000,000). Rates were significantly higher among Hispanic White persons (2.8 per 1,000,000) compared to non-Hispanic White persons. For all other melanoma types, incidence rates were significantly higher among non-Hispanic White persons compared to persons in each of the other racial and ethnic categories. The percentage of melanomas that were ALM ranged from 0.8% among non-Hispanic White persons to 19.1% among Hispanic Black, AI/AN, and API persons. CONCLUSION: These findings suggest that awareness of the potential for ALM in patients of all races and ethnicities could be balanced with an understanding of the rarity of the disease and the potential for the development of other melanoma types in racial and ethnic minority groups.

Economic burden of skin cancer treatment in the USA: an analysis of the Medical Expenditure Panel Survey Data, 2012-2018.

PURPOSE: We report the prevalence and economic cost of skin cancer treatment compared to other cancers overall in the USA from 2012 to 2018. METHODS: Using the Medical Expenditure Panel Survey full-year consolidated data files and associated medical conditions and medical events files, we estimate the prevalence, total costs, and per-person costs of treatment for melanoma and non-melanoma skin cancer among adults aged ≥ 18 years in the USA. To understand the changes in treatment prevalence and treatment costs of skin cancer in the context of overall cancer treatment, we also estimate the prevalence, total costs, and per-person costs of treatment for non-skin cancer among US adults. RESULTS: During 2012-15 and 2016-18, the average annual number of adults treated for any skin cancer was 5.8 (95% CI: 5.2, 6.4) and 6.1 (95% CI: 5.6, 6.6) million, respectively, while the average annual number of adults treated for non-skin cancers rose from 10.8 (95% CI: 10.0, 11.5) to 11.9 (95% CI: 11.2, 12.6) million, respectively. The overall estimated annual costs rose from $8.0 (in 2012-2015) to $8.9 billion (in 2016-18) for skin cancer treatment and $70.2 to $79.4 billion respectively for non-skin cancer treatment. CONCLUSION: The prevalence and economic cost of skin cancer treatment modestly increased in recent years. Given the substantial cost of skin cancer treatment, continued public health attention to implementing evidence-based sun-safety interventions to reduce skin cancer risk may help prevent skin cancer and the associated treatment costs.

Sunless and Indoor Tanning Among U.S. Non-Hispanic White Women Ages 18-49 Years.

The use of indoor UV tanning devices (also known as "indoor tanning") has declined in recent years. Less is known about use of dihydroxyacetone-containing products used for tanning (also known as "sunless tanning"). We analyzed data from the 2015 National Health Interview Survey. Analysis was limited to non-Hispanic White women ages 18-49 years. We estimated the proportion of women reporting spray tanning, self-applied lotion tanning, and indoor tanning and used weighted multivariable logistic regression models to examine the relationships between socio-demographic characteristics, skin cancer risk factors, and other cancer risk factors with sunless and indoor tanning. Overall, 17.7% of women reported sunless tanning. Lotion tanning was more common (15.3%) than spray tanning (6.8%), while 12.0% of women engaged in indoor tanning. Among sunless tanners, 23.7% also engaged in indoor tanning. Younger age, ever having a skin exam, skin reactions to the sun, binge drinking, and being at a healthy weight were associated with sunless tanning. While sunless tanning may be less harmful for skin cancer risk than indoor tanning, the frequency with which the two behaviors co-occur suggests that efforts to address societal pressures for women to alter their skin color may have important public health benefits.

Beliefs Associated with Sunscreen use among non-Hispanic white Older Adults.

This study examines beliefs about sunscreen use among non-Hispanic white adults aged 50 years or older using online survey data (n=237). Multiple logistic regression analyses were conducted to examine beliefs associated with sunscreen use, adjusted by age, gender, education, geographic location, and skin cancer risk score. Those who believed sunscreen use would prevent them from getting sunburned (odds ratio [OR]=1.84) and those who believed that their romantic partners thought they should use sunscreen (OR=1.72) were more likely to report sunscreen use. Those who believed sunscreen use would "take too much time" were less likely to report sunscreen use (OR=0.65). These findings can inform future research and messaging efforts, including the evaluation of intervention approaches that highlight the immediate benefits of sunscreen use, address concerns about sunscreen use taking too much time, and tap into the potential influence that older adults may have on the sunscreen use of their romantic partners.

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.

Examination of Laws Allowing Sunscreen Use in Schools in the Context of UV Levels by State.

PURPOSE: Sunscreen use provides ultraviolet radiation (UV) protection but is often limited in school settings because sunscreen is classified as an over-the-counter drug product. Some US states have laws allowing students to carry and self-apply sunscreen. We examined these laws in the context of state UV levels. METHODS: We obtained legislative information through April 2020 from the American Society for Dermatologic Surgery Association website and UV data for years 2005-2015 from Centers for Disease Control and Prevention's National Environmental Public Health Tracking website. RESULTS: Twenty-three states and District of Columbia have sunscreen laws, including 11 states with UV levels above the median UV level across states. There was no significant association between state UV levels and sunscreen laws. CONCLUSIONS: The presence of state sunscreen legislation has increased but is not associated with UV levels. Future research could examine the implementation and public health effects of these laws.

Cancer Risk Among Older Adults: Time for Cancer Prevention to Go Silver.

Over two-thirds of all new cancers are diagnosed among adults aged ≥60 years. As the number of adults living to older ages continues to increase, so too will the number of new cancer cases. Can we do more as a society to reduce cancer risk and preserve health as adults enter their 60s, 70s, and beyond? Cancer development is a multi-step process involving a combination of factors. Each cancer risk factor represents a component of cancer causation, and opportunities to prevent cancer may exist at any time up to the final component, even years after the first. The characteristics of the community in which one lives often shape cancer risk-related behaviors and exposures over time, making communities an ideal setting for efforts to reduce cancer risk at a population level. A comprehensive approach to cancer prevention at older ages would lower exposures to known causes of cancer, promote healthy social and physical environments, expand the appropriate use of clinical preventive services, and engage older adults in these efforts. The collection of articles in this supplement provide innovative insights for exciting new directions in research and practice to expand cancer prevention efforts for older adults. This brief commentary sets the stage for the papers that follow.

Clinical counseling on sun protection and indoor tanning avoidance: A survey of current practices among U.S. health care providers.

Clinicians can play a role in skin cancer prevention by counseling their patients on use of sun protection and indoor tanning avoidance. We used data from the 2016 DocStyles, a web-based survey of U.S. primary care providers, to examine skin cancer prevention counseling practices among 1506 providers. In 2018, we conducted logistic regression analyses to examine factors associated with regularly providing counseling. Almost half (48.5%) of all providers reported regularly counseling on sun protection, and 27.4% reported regularly counseling on indoor tanning. Provider characteristics associated with regular counseling included having practiced medicine for at least 16 years (sun protection: adjusted prevalence ratio [aPR] = 1.27, 95% confidence interval [CI] = 1.15, 1.41; indoor tanning: aPR = 1.38, 95% CI = 1.17, 1.63), having treated sunburn in the past year (sun protection: aPR = 1.78, 95% CI = 1.46, 2.17; indoor tanning: aPR = 2.42, 95% CI = 1.73, 3.39), and awareness of U.S. Preventive Services Task Force recommendations (sun protection: aPR = 1.73, 95% CI = 1.51, 2.00; indoor tanning: aPR = 2.70, 95% CI = 2.09, 3.48). Reporting barriers to counseling was associated with a lower likelihood of regularly counseling on sun protection (1-3 barriers: aPR = 0.82, 95% CI = 0.71, 0.94; 4+ barriers: aPR = 0.80, 95% CI = 0.69, 0.93) and indoor tanning (1-3 barriers: aPR = 0.72, 95% CI = 0.57, 0.91; 4+ barriers: aPR = 0.61, 95% CI = 0.47, 0.78). Barriers to counseling included lack of time (58.1%), more urgent health concerns (49.1%), and patient disinterest (46.3%). Although many providers report regularly counseling patients on skin cancer prevention, most report serious barriers to providing such counseling. Additional research could explore strategies to integrate compelling and informative skin cancer prevention counseling into current provider practices.

Prevalence of Indoor Tanning Among U.S. High School Students from 2009 to 2017.

Indoor tanning exposes users to high levels of ultraviolet radiation, increasing skin cancer risk. The risk is greatest for those who begin indoor tanning at a young age. The objective of this study was to assess changes in indoor tanning prevalence over time among U.S. high school students, by sex, age, and race/ethnicity. We used cross-sectional data from the 2009, 2011, 2013, 2015, and 2017 national Youth Risk Behavior Survey to examine changes in indoor tanning prevalence from 2009 to 2017 and from 2015 to 2017. From 2009 to 2017 indoor tanning declined overall (15.6 to 5.6%; p < 0.001), across all age groups, and among white (37.4 to 10.1%; p < 0.001) and Hispanic (10.5 to 3.0%; p < 0.001) female students, and white (7.0 to 2.8%; p < 0.001) and Hispanic (5.8 to 3.4%; p < 0.001) male students. From 2015 to 2017, indoor tanning declined overall (7.3 to 5.6%; p = 0.04) and among white (15.2 to 10.1%; p = 0.03) and Hispanic (5.8 to 3.0%; p = 0.02) female students, and 16-year-old students (7.2 to 4.7%; p = 0.03). Indoor tanning has continued to decrease, particularly among white and Hispanic female students, dropping well below the Healthy People 2020 target for adolescents. However, continued efforts are needed to further reduce and sustain reductions in adolescent indoor tanning and address remaining research gaps.

Association Between Sun Protection Behaviors and Sunburn Among U.S. Older Adults.

BACKGROUND AND OBJECTIVES: Skin cancer incidence rates are highest among U.S. older adults. However, little is known about sun protection behaviors and sunburn among adults aged 65 years and older. RESEARCH DESIGN AND METHODS: We used data from the 2015 National Health Interview Survey to examine the association between sun protection behaviors (sun avoidance, wearing protective clothing, and sunscreen use) and likelihood of having experienced sunburn in the past year. RESULTS: Just over one in ten older adults (13.2%) had experienced sunburn in the past year; sunburn prevalence was nearly twice as high (20.4%) among sun-sensitive older adults. Men, ages 65-69 years, non-Hispanic whites, and those with skin that burns or freckles after repeated sun exposure were more likely to have been sunburned in the past year compared with the respective comparison groups. The only sun protection behavior significantly associated with sunburn was sunscreen use. None of the sun protection behaviors were significantly associated with a decreased risk of sunburn. DISCUSSION AND IMPLICATIONS: The prevalence of sunburn among older adults suggests opportunities to reduce skin cancer risk within this demographic group by preventing overexposure to the sun. The lack of reduced sunburn risk among those who regularly used sun protection may be related to inadequate or inconsistent use of sun protection or the way the sun protection behaviors were measured. Multi-sector approaches to facilitate sun-safety among older adults are warranted and could include targeted efforts focused on those most likely to get sunburned, including men and those with sun-sensitive skin.

Skin Cancer Prevention Behaviors Among Agricultural and Construction Workers in the United States, 2015.

INTRODUCTION: Nearly 5 million people are treated for skin cancer each year in the United States. Agricultural and construction workers (ACWs) may be at increased risk for skin cancer because of high levels of ultraviolet radiation exposure from the sun. This is the first study that uses nationally representative data to assess sun-protection behaviors among ACWs. METHODS: We analyzed data from the 2015 National Health Interview Survey Cancer Control Supplement to examine the prevalence of sun-protection behaviors among ACWs. We calculated national, weighted, self-reported prevalence estimates. We used χ2 tests to assess differences between ACWs by industry and occupation. RESULTS: Most of the 2,298 agricultural and construction workers studied were male (by industry, 72.4% in agriculture and 89.3% in construction; by occupation, 66.1% in agriculture and 95.6% in construction) and non-Hispanic white. About one-third had at least 1 sunburn in the past year. The prevalence of sunscreen use and shade seeking was low and did not significantly differ among groups, ranging from 15.1% to 21.4% for sunscreen use and 24.5% to 29.1% for shade seeking. The prevalence of wearing protective clothing was significantly higher among agricultural workers than among construction workers by industry (70.9% vs 50.7%) and occupation (70.5% vs 53.0%). CONCLUSION: Our findings could be used to improve occupational health approaches to reducing skin cancer risk among ACWs and to inform education and prevention initiatives addressing skin cancer. Sun-safety initiatives may include modifying work sites to increase shade and adding sun safety to workplace policies and training. Employers can help reduce occupational health inequities and protect workers by creating workplaces that facilitate sun protection.

Adverse Childhood Experiences and the Presence of Cancer Risk Factors in Adulthood: A Scoping Review of the Literature From 2005 to 2015.

Exposure to Adverse Childhood Experiences (ACEs) is associated with a host of harmful outcomes, including increased risk for cancer. A scoping review was conducted to gain a better understanding of how ACEs have been studied in association with risk factors for cancer. This review includes 155 quantitative, peer-reviewed articles published between 2005 and 2015 that examined associations between ACEs and modifiable cancer risk factors, including alcohol, environmental carcinogens, chronic inflammation, sex hormones, immunosuppression, infectious agents, obesity, radiation, ultraviolet (UV) radiation, and tobacco, among U.S. adults. This review highlights the growing body of research connecting ACEs to cancer risk factors, particularly alcohol, obesity, and tobacco. Fewer studies investigated the links between ACEs and chronic inflammation or infectious agents. No included publications investigated associations between ACEs and environmental carcinogens, hormones, immunosuppression, radiation, or ultraviolet radiation. Mitigating the impact of ACEs may provide innovative ways to effect comprehensive, upstream cancer prevention.

Skin cancer knowledge, awareness, beliefs and preventive behaviors among black and hispanic men and women.

Black and Hispanic populations perceive their skin cancer risk to be low and are less likely to use sun protection strategies. We conducted formative research to understand knowledge, awareness, beliefs, and behaviors among these groups. In 2017, eighteen focus groups were conducted with black and Hispanic respondents(18-44 years) in four US cities. Groups were segmented by participant characteristics associated with elevated or lower risk for skin cancer, by race/ethnicity, gender, and age. A professional moderator followed a semi-structured discussion guide, and focus group transcripts were analyzed using conventional content analysis and NVIVO 11 Software. Most participants perceived themselves to be at low skin cancer risk due to their "darker skin tone" and/or "lack of family history." Skin cancer signs and symptoms were more inconsistently reported by blacks than Hispanics. Few participants reported regular sun protection behaviors. Those who did used sunscreen, wore protective clothing, and had elevated risk based on sun sensitivity or UV exposure. While most participants recalled family discussions (as youth) about sunscreen and sun protection, the understood intent was to warn against "further skin darkening" or to "prevent aging," not to reduce sun burns or skin cancer risk. Tanning bed use was low across all segments, especially among black respondents. Tailored skin cancer prevention campaigns need to address misperceptions about risks and benefits of skin cancer prevention behaviors among black and Hispanic populations. Families, peer groups, and healthcare providers need to be engaged in the creation of educational interventions and messaging efforts that target these populations.

Shade as an Environmental Design Tool for Skin Cancer Prevention.

Little work has been done to explore the use of shade for skin cancer prevention in the context of the built environment. In an effort to address this gap and draw attention to the intersection between architectural and public health practice, we reviewed research on shade design, use, and policies published from January 1, 1996, through December 31, 2017. Our findings indicate that various features influence the sun-protective effects of shade, including the materials, size, shape, and position of the shade structure; the characteristics of the surrounding area; and weather conditions. Limited research suggests that shade provision in outdoor spaces may increase shade use. Shade audit and design tools are available to inform shade planning efforts. Shade policies to date have mostly been setting specific, and information on the implementation and effects of such policies is limited. Integrating shade planning into community design, planning, and architecture may have a substantial impact and will require a multidisciplinary approach.

State Indoor Tanning Laws and Prevalence of Indoor Tanning Among US High School Students, 2009-2015.

OBJECTIVES: To examine the association between state indoor tanning laws and indoor tanning behavior using nationally representative samples of US high school students younger than 18 years. METHODS: We combined data from the 2009, 2011, 2013, and 2015 national Youth Risk Behavior Surveys (n = 41 313) to analyze the association between 2 types of state indoor tanning laws (age restriction and parental permission) and the prevalence of indoor tanning during the 12 months before the survey, adjusting for age, race/ethnicity, and survey year, and stratified by gender. RESULTS: Age restriction laws were associated with a 47% (P < .001) lower indoor tanning prevalence among female high school students. Parental permission laws were not found to be associated with indoor tanning prevalence among either female or male high school students. CONCLUSIONS: Age restriction laws could contribute to less indoor tanning, particularly among female high school students. Such reductions may reduce the health and economic burden of skin cancer.