Abstract
Background:
Although skin cancer survivors have an increased risk of future malignancies, many are unaware of this and may not undergo preventative screening.
Objective:
To evaluate skin cancer survivors’ prevalence of breast, colorectal, cervical, and lung cancer screening.
Methods:
This is a retrospective cross-sectional analysis of The Behavioral Risk Factor Surveillance System database from 2017 to 2021 comparing skin cancer, other cancer, and non-cancer controls. Multivariate analysis compared screening rates, controlled for socioeconomic, chronic disease, and behavioral factors.
Results:
Compared to non-cancer controls, skin cancer survivors had higher odds of undergoing screening for breast (odds ratios [OR]: 1.35, 95% confidence interval [CI] 1.20–1.51), colorectal (OR 1.53, 95% CI 1.40–1.66), and cervical cancer (OR 1.32, 95% CI 1.12–1.56). Lung cancer screening rates were low and similar between skin cancer survivors and non-cancer individuals (OR 1.21, 95% CI 0.84–1.74). In a subset analysis of skin cancer survivors, those who had melanoma were less likely to be screened for breast and colorectal cancer.
Limitations:
This study is based on anonymous, national survey data, relying on patient recall of their health information.
Conclusion:
Skin cancer survivors undergo cancer screenings for breast, colorectal, and cervical cancer at higher rates compared to non-cancer controls. Melanoma survivors have lower rates of breast and colorectal screening compared to non-melanoma skin cancer survivors. Skin cancer survivors should be reminded of preventive cancer screening, particularly for lung cancer.
Keywords: breast cancer, cancer screening, cervical cancer, colorectal cancer, lung cancer, screening, skin cancer
What is known about this subject with respect to women and their families?
It is known that women are at high risk of other malignancy if they have been diagnosed with skin cancer in the past. It is also recognized that having had skin cancer in the past can change your actions in the future, specifically regarding sun safety.
What is new in this article with respect to women and their families?
This article found that women with a history of skin cancer are up-to-date on most routine preventative cancer screening and have higher rates of cervical cancer and breast cancer screening compared to people with no history of cancer. However, melanoma survivors had a lower rate of lung cancer and colon cancer screening, suggesting an opportunity to impact women’s health if providers make changes in their counseling or record keeping to emphasize the importance of these screening tools.
Introduction
Skin cancer is one of the most common human malignancies.1–3 For melanoma and non-melanoma skin cancer (NMSC) survivors, studies have shown a significantly higher risk of developing a second skin cancer or a second primary other malignancy compared to patients without prior skin cancer.4–10 Specifically, a systematic review of melanoma survivors found an increased risk of all cancers (summary relative risk [SRR] = 1.57, 95% confidence interval [CI] 1.29–1.90), with increased risk specifically for non-melanoma skin cancer, colorectal cancer, and breast cancer.9 Similarly, a systematic review of NMSC survivors found an increased risk of all cancers (SRR 1.12, 95% CI 1.07–1.17), with increased risk specifically for melanoma and lung cancer.10
Although skin cancer survivors are at increased risk for future malignancy, they may not be aware of this risk or implement preventive screening. Rhee et al. found that NMSC survivors believed they were at increased risk for another NMSC but not at increased risk to develop melanoma or another primary cancer compared to the general population. They also found an increase in skin self-exam and sun-protective behavior after surgical treatment but no significant changes in other behaviors that affect cancer risk, such as alcohol consumption, tobacco use, exercise, or diet.11 A study of skin cancer patients following Mohs micrographic surgery found that although survivors were more likely to increase sun-protective habits and self-skin checks, they were not more likely to get skin checks by a physician, seek physician care for other health matters, or believe they were at higher risk of other cancers.12 Oliveria et al. reported that melanoma survivors acknowledge the importance of increased sun safety and skin cancer monitoring, but not all patients continue these more rigorous habits after recovery and did not consider themselves to be “survivors.”13
Based on these attitudes and behaviors, one may be curious whether a previous skin cancer diagnosis is associated with other preventive cancer screenings. Previous studies on skin cancer survivors’ screening prevalence are limited by screening type or exclude NMSC,14,15 indicating a study regarding skin cancer survivors’ screening prevalence across screening types and amongst both melanoma and NMSC is needed. Therefore, this study aims to determine the prevalence of breast cancer, colorectal cancer, cervical cancer, and lung cancer screening in skin cancer survivors, including both melanoma and NMSC survivors.
Methods
Study setting
This study is conducted using The Behavioral Risk Factor Surveillance System (BRFSS) from 2017 to 2021, a system of United States (US) telephone-based surveys. The survey is conducted across all 50 states, the District of Columbia, and 3 US territories and includes over 400,000 adults over the age of 18 each year. The only exclusion criterion is lack of telephone access.16
Study design and population
This is a retrospective cross-sectional study of preventative cancer screening prevalence in skin cancer survivors, other cancer survivors, and non-cancer individuals. The skin cancer group was further subclassified as melanoma and NMSC survivors, when possible, based on annual questionnaire availability by state (Mendley Supplemental Table 1, Supplemental Digital Content 1, https://links.lww.com/IJWD/A95).
Cancer screening eligibility was determined following the 2024 US Preventative Services Task Force (USPSTF) Grade A and B recommendations from 2024 (Mendeley Supplemental Table 2, Supplemental Digital Content 2, https://links.lww.com/IJWD/A96).17 Individuals were considered compliant for a respective cancer screening if they met any of the screening recommendations, not compliant if they failed to meet all the screening recommendations, and unable to determine if they failed to meet some recommendations and had unknown responses for others.
Based on the recommendations, men and women aged 21 to 75 are included in this study. Although lung cancer screening is recommended up-to age 80, the non-continuous nature of the age variable in BRFSS required us to exclude those over 75. Other exclusion criteria included unknown answers to cancer history or sex. Cancer survivors with a history of breast, colorectal, cervical, or lung cancer were excluded from that respective screening analysis. Those whose screening status could not be ascertained were excluded from the respective cancer screening analysis.
Measures
Other variables included demographics, socioeconomic status, chronic disease, and behavioral risk factors. Some variables need additional explanation. Marital status is “married,” “not married,” indicating never married or member of an unmarried couple, and “other,” indicating divorced, widowed, or separated. Chronic medical conditions include cardiovascular, respiratory, psychiatric, renal (excluding kidney stones, bladder infection or incontinence), diabetes mellitus, and arthritis/autoimmune diseases. Individuals were categorized as having none, 1 to 2, or 3 to 6 of these conditions. Rural area status is unknown if the interviewee is in a US territory or using a cell phone. Binge drinking is defined as having 5 or more drinks for men or 4 or more drinks for women on any occasion during the past 30 days. The BRFSS questionnaire varies year to year, and each year’s survey questions are available at https://www.cdc.gov/brfss/questionnaires/index.htm.
Statistical analysis
BRFSS-recommended survey weights were used to standardize results relative to the number of responders per year. Unweighted frequency and weighted percentages were reported to characterize the differences in socioeconomic factors, chronic medical conditions, and behavioral risk factors across the 3 cancer groups using the Rao–Scott Chi-Square test. Univariate logistic regression analysis was conducted to compare screening rates with non-cancer individuals aged 50 to 59 as the reference group. Multivariate logistic regression analysis was performed, with the same reference group, controlling for socioeconomic, chronic disease, and behavioral variables. Results are provided with odds ratios (OR), adjusted OR for multivariate results, 95% confidence intervals (CI), and P-value as the output. “Unknown” was included as a category for variables with unknown, missing, or refused responses that accounted for >5% of the variable’s eligible cases. The P-value of statistical significance was set as P < .05. Data was analyzed using SAS version 9.4 (SAS Institute Inc.).
Results
Cohort characteristics
About 124,828 skin cancer survivors met inclusion criteria, of whom 4,258 reported melanoma and 8,615 reported NMSC as their only previous cancer. Skin cancer survivors are compared to 136,799 other cancer survivors and 1,616,626 non-cancer controls (Fig. 1). The median age is higher in skin cancer (67.0 years) and other cancer (66.0 years) groups compared to the non-cancer group (53.0 years). Sex is balanced among the groups (skin cancer 59.8% female, non-cancer 50.4% female) except for a higher percentage of females (63%) in the other cancer group. Skin cancer survivors were most frequently white, non-Hispanic (93.6%), with insurance (96.5%), income > $50,000 per year (51.7%), with a bachelor’s or higher degree (37.7%), married (68.1%), and with a recent checkup (85.2%) and primary care provider (93.2%). Melanoma and NMSC cohorts were overall similar (Mendeley Supplemental Table 3, Supplemental Digital Content 3, https://links.lww.com/IJWD/A97). Other cancer and non-cancer groups had more racial and ethnic diversity (71.7% and 59.1% White, non-Hispanic, respectively). Compared to cancer survivors, non-cancer individuals were more frequently uninsured (12.9%), without chronic health conditions (55.5%), and without a recent checkup (27.8%) or primary care provider (20%) (Table 1).
Fig. 1.
The skin cancer group had history skin cancer but no other cancer, the other cancer group had history of a non-skin cancer but no history of skin cancer, and the non-cancer group had no history of cancer. *Only certain states each year answered the cancer survivor module, so many skin cancer patients have an unspecified type.
Table 1.
Demographics and socioeconomic, chronic medical condition, and behavioral risk factors of the population
| Characteristic | Skin cancer n (%) |
Other cancer n (%) |
Non-cancer n (%) |
Total N |
Rao–Scott chi-square P-value | |||
|---|---|---|---|---|---|---|---|---|
| Age: median (IQR) | 67.0 | (13.0) | 66.0 | (15.0) | 53.0 | (26.0) | 56 (25.0) | <.0001 |
| Age group | ||||||||
| 21–29 | 821 | (1.4) | 1,756 | (2.6) | 181,984 | (18.2) | 184,561 | <.0001 |
| 30–39 | 2,456 | (3.6) | 5,587 | (6.9) | 244,393 | (21.1) | 252,436 | |
| 40–49 | 6,968 | (8.4) | 10,521 | (10.9) | 244,393 | (18.4) | 276,901 | |
| 50–59 | 20,901 | (20.6) | 24,387 | (21.2) | 333,104 | (18.5) | 378,392 | |
| 60–69 | 43,687 | (32.8) | 46,308 | (30.4) | 365,317 | (15.3) | 455,312 | |
| 70–79 | 49,995 | (33.2) | 48,240 | (28.0) | 232,416 | (8.4) | 330,651 | |
| Sex | ||||||||
| Male | 60,146 | (50.2) | 48,722 | (37.0) | 752,046 | (49.6) | 860,914 | <.0001 |
| Female | 64,682 | (59.8) | 88,077 | (63.0) | 864,580 | (50.4) | 1,017,339 | |
| Race/ethnicity | ||||||||
| White | 116,959 | (93.6) | 108,358 | (71.7) | 1,149,801 | (59.1) | 1,375,118 | <.0001 |
| Black | 641 | (0.9) | 10,507 | (11.3) | 140,558 | (12.8) | 151,706 | |
| Asian | 202 | (0.4) | 1,522 | (2.5) | 44,103 | (6.0) | 45,827 | |
| Hispanic | 1,856 | (3.2) | 7,083 | (11.2) | 161,406 | (18.9) | 170,345 | |
| Other | 2,971 | (1.9) | 6,711 | (3.3) | 85,976 | (3.1) | 151,706 | |
| Insurance | ||||||||
| Yes | 121,035 | (96.5) | 130,790 | (94.8) | 1,455,884 | (87.1) | 196,104,105 | <.0001 |
| No | 2,980 | (3.5) | 4973 | (5.2) | 144,322 | (12.9) | 26,797,686 | |
| Income level | ||||||||
| <$50K | 39,947 | (30.3) | 59,787 | (42.9) | 619,841 | (38.5) | 719,575 | <.0001 |
| >$50K | 62,389 | (51.7) | 51,911 | (38.5) | 718,729 | (43.8) | 833,029 | |
| Unknown | 22,492 | (17.9) | 25,101 | (18.6) | 278,056 | (17.7) | 325,649 | |
| Education | ||||||||
| GED or less | 30,520 | (29.7) | 44,497 | (39.4) | 525,109 | (39.1) | 600,126 | <.0001 |
| Some college | 33,889 | (32.6) | 40,295 | (32.8) | 444,895 | (30.4) | 519,079 | |
| College + | 60,099 | (37.7) | 51,581 | (27.8) | 639,570 | (30.5) | 751,250 | |
| Marital status | ||||||||
| Married | 79,866 | (68.1) | 72,877 | (56.7) | 867,438 | (52.9) | 1,020,181 | <.0001 |
| Not married | 10,120 | (8.4) | 15,871 | (13.3) | 360,279 | (28.9) | 386,270 | |
| Other | 34,035 | (23.5) | 47,096 | (30.1) | 374,456 | (18.2) | 455,587 | |
| Rural area | ||||||||
| Yes | 19,444 | (7.0) | 20,977 | (6.4) | 168,361 | (3.7) | 208,782 | <.0001 |
| No | 37,109 | (26.1) | 39,014 | (25.2) | 302,527 | (14.5) | 378,650 | |
| Unknown | 68,275 | (66.9) | 76,808 | (68.4) | 1,145,738 | (81.8) | 1,290,821 | |
| Last checkup | ||||||||
| <1 year ago | 107,003 | (85.2) | 119,587 | (86.9) | 1,205,600 | (72.2) | 1,432,190 | <.0001 |
| >1 year/never | 16,999 | (14.8) | 15,947 | (13.1) | 391,171 | (27.8) | 424,117 | |
| Has primary care provider | ||||||||
| Yes | 117,574 | (93.2) | 128,990 | (93.1) | 1,363,016 | (80.0) | 182,318,029 | <.0001 |
| No | 6,960 | (6.8) | 7,427 | (6.9) | 247,685 | (20.0) | 262,072 | |
| BMIa | ||||||||
| Normal | 36,626 | (28.7) | 36,188 | (26.5) | 443,104 | (28.1) | 515,918 | <.0001 |
| Overweight | 44,639 | (35.7) | 43,764 | (31.5) | 521,578 | (31.6) | 609,981 | |
| Obese | 34,976 | (28.2) | 45,657 | (33.3) | 496,149 | (29.5) | 576,782 | |
| Unknown | 8,587 | (7.4) | 11,190 | (8.7) | 155,795 | (10.7) | 175,572 | |
| Number of chronic medical conditions | ||||||||
| 0 (none) | 39,867 | (34.2) | 37,376 | (29.2) | 781,882 | (55.5) | 859,125 | <.0001 |
| 1–2 | 66,131 | (52.9) | 71,733 | (53.3) | 675,563 | (38.4) | 813,427 | |
| 3+ | 15,951 | (12.9) | 23,793 | (17.1) | 124,760 | (6.1) | 164,504 | |
| Smoking status | ||||||||
| Current | 12,515 | (12.0) | 20,281 | (16.8) | 239,709 | (16.2) | 272,505 | <.0001 |
| Former | 42,787 | (35.4) | 46,988 | (34.3) | 396,892 | (23.0) | 486,667 | |
| Never | 65,178 | (52.6) | 64,403 | (48.6) | 902,035 | (60.8) | 1,031,616 | |
| Binge drinking | ||||||||
| Yes | 11,215 | (10.9) | 10,300 | (8.8) | 231,140 | (16.3) | 252,655 | <.0001 |
| No | 107,033 | (82.9) | 118,767 | (84.4) | 1,267,622 | (74.9) | 1,493,422 | |
| Unknown | 6,580 | (6.2) | 7,732 | (6.7) | 117,864 | (8.7) | 132,176 | |
| Exerciseb | ||||||||
| Yes | 95,837 | (77.9) | 91,967 | (68.0) | 1,188,657 | (75.6) | 1,376,461 | <.0001 |
| No | 26,516 | (22.1) | 41,720 | (32.0) | 382,759 | (24.4) | 450,995 | |
BMI: normal <18.5–24.9; overweight = 25.0–29.9; obese >30.0.
Exercise is in the last 30 days.
Breast cancer screening
Breast cancer screening prevalence in skin cancer survivors was 83.6%, compared to 80.1% in other cancer survivors and 77.7% in non-cancer individuals (Table 2). Skin cancer survivors had higher odds of undergoing recommendation-concordant breast cancer screening (adjusted OR 1.35; 95% CI 1.20–1.51; P < .0001), whereas other cancer survivors did not have increased screening (adjusted OR 1.02; 95% CI 0.92–1.13; P = 0.73) (Fig. 2A). Of skin cancer survivors, melanoma survivors had a lower prevalence of breast cancer screening compared to NMSC survivors (78.4% vs 85.6%) (Table 2), and accordingly, only NMSC survivors had higher odds of undergoing recommendation-concordant screening (adjusted OR 1.37; 95% CI 1.08–1.74; P = .0095) (Fig. 2A).
Table 2.
Screening rate for cancer screenings amongst skin cancer, other cancer, and non-cancer groups
| Recommendation-concordant | Breast cancer screening | Colorectal cancer screening | Cervical cancer screening | Lung cancer screening | ||||
|---|---|---|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | n (%) | |||||
| Skin Cancer | 11,764 | (83.6) | 24,326 | (82.1) | 5,352 | (89.4) | 279 | (22.6) |
| Melanoma | 702 | (78.4) | 1,565 | (75.1) | 378 | (91.9) | 21 | (18.7) |
| NMSC | 1,948 | (85.6) | 3,492 | (83.4) | 844 | (89.3) | 27 | (17.5) |
| Other cancer | 16,516 | (80.1) | 30,930 | (81.8) | 7,978 | (88.2) | 692 | (43.7) |
| Non-cancer | 133,439 | (77.7) | 227,017 | (64.9) | 160,465 | (82.3) | 2,114 | (15.7) |
Fig. 2.
Multivariate adjusted analysis compared to non-cancer controls: Circle = odds ratio and line = confidence interval. The dot is red with * if P < 0.05. (A) Skin cancer and non-melanoma skin cancer (NMSC) survivors have higher odds of undergoing breast cancer screening. (B) Skin cancer and other cancer survivors have higher odds of undergoing colorectal cancer screening. (C) Skin cancer, melanoma, and other cancer survivors have higher odds of undergoing cervical cancer screening. (D) Other cancer survivors have higher odds of undergoing lung cancer screening.
Colorectal cancer screening
Colorectal cancer screening prevalence in skin cancer survivors, other cancer survivors, and non-cancer individuals was 82.1%, 81.8%, and 64.9%, respectively (Table 2). Skin cancer survivors had higher odds of having recommendation-concordant colorectal cancer screening (adjusted OR 1.53; 95% CI 1.40–1.66; P <.0001), as did other cancer survivors (adjusted OR 1.60; 95% CI 01.47–1.74; P <.0001) (Fig. 2B). Of skin cancer survivors, melanoma survivors had a lower prevalence of colorectal cancer screening compared to NMSC survivors (75.1% vs 83.4%) (Table 2). Therefore, only NMSC survivors had higher odds of having recommendation-concordant screening (adjusted OR 1.64; 95% CI 1.42–1.90; P <.0001), whereas melanoma survivors had a similar screening rate as their non-cancer counterparts (adjusted OR 1.04; 95% CI 0.85–1.28; P = 0.69) (Fig. 2B).
Cervical cancer screening
Cervical cancer screening prevalence was highest in skin cancer survivors (82.5%), followed by other cancer survivors (79.3%) and non-cancer individuals (76.6%) (Table 2). Skin cancer survivors had higher odds of undergoing recommendation-concordant cervical cancer screening (adjusted OR 1.32; 95% CI 1.12–1.56; P = 0.0011); and other cancer survivors had similarly increased odds (adjusted OR 1.29; 95% CI 1.09–1.53; P = 0.0029) (Fig. 2C). Only melanoma survivors had higher odds of cervical cancer screening (adjusted OR 1.72; 95% CI 1.14–2.59; P = .0092), whereas NMSC survivors did not (adjusted OR 1.24, 95% CI 0.89–1.72; P = 0.21) (Figure 2C).
Lung cancer screening
Lung cancer screening prevalence was less than 50% across all groups; other cancer survivors had the highest rate (43.7%), then skin cancer survivors (22.6%) and non-cancer individuals (15.7%) (Table 2). Other cancer survivors had increased odds of screening (adjusted OR 3.20; 95% CI 2.49–4.12; P < .0001). In the unadjusted analysis, skin cancer survivors had higher odds of screening (OR 1.56; 95% CI 1.11–2.20, P = 0.01) (Mendeley Supplemental Table 4, Supplemental Digital Content 4, https://links.lww.com/IJWD/A98). However, after adjusting for demographics, chronic health, and behavioral risk factors, they had a similar screening rate compared to non-cancer individuals (adjusted OR 1.21; 95% CI 0.84–1.74; P = .31) (Fig. 2D). Melanoma and NMSC survivors had similar rates of recommendation-concordant lung cancer screening (18.7% and 17.5%) (Table 2), and neither was increased compared to non-cancer controls (Fig. 2D).
Socioeconomic, chronic medical condition, and behavioral risk factors
Factors that significantly increased all cancer screening types include having insurance, a checkup within the last year, and having a primary care provider (all P-values < .05) (Table 3). Other factors that increased screening in most, but not all, cancer screening types were Black race, income >$50,000 per year, higher education, being married, non-rural residence, multiple chronic medical conditions, and exercise (Table 3).
Table 3.
Multivariate adjusted analysis: odds of cancer screening for skin cancer (melanoma, NMSC) and other cancer; demographics and socioeconomic, chronic medical condition, and behavioral risk factors
| Breast cancer screening | Colorectal cancer screening | Cervical cancer screening | Lung cancer screening | |||||
|---|---|---|---|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | OR | 95% CI | OR | 95% CI | |
| Age group (Ref = 50–59) | ||||||||
| 21-29 | – | – | 0.65 | (0.60–0.72) | – | – | ||
| 30–39 | – | – | 1.77 | (1.60–1.95) | ||||
| 40–49 | – | – | 1.31 | (1.19–1.43) | ||||
| 60–69 | 1.12 | (1.05–1.19) | 1.94 | (1.86–2.03) | 0.69 | (0.63–0.76) | 1.38 | (1.08–1.78) |
| 70–79a | 1.07 | (0.98–1.17) | 2.56 | (2.40–2.72) | – | 1.57 | (1.14–2.17) | |
| Sex (Ref = Female) | ||||||||
| Male | – | 0.95 | (0.91–0.99) | – | 1.07 | (0.84–1.36) | ||
| Race/ethnicity (Ref = White) | ||||||||
| Black | 1.71 | (1.55–1.88) | 1.15 | (1.08–1.23) | 1.34 | (1.22–1.47) | 0.71 | (0.49–1.02) |
| Asian | 0.89 | (0.66–1.20) | 0.63 | (0.54–0.73) | 0.43 | (0.37–0.49) | 2.40 | (0.59–9.83) |
| Hispanic | 1.56 | (1.35–1.81) | 0.85 | (0.79–0.92) | 1.34 | (1.23–1.46) | 1.03 | (0.38–2.76) |
| Other | 0.97 | (0.84–1.12) | 0.81 | (0.74–0.89) | 0.90 | (0.80–1.01) | 0.78 | (0.47–1.28) |
| Insurance (Ref = Yes) | ||||||||
| No | 0.51 | (0.46–0.57) | 0.50 | (0.46–0.54) | 0.69 | (0.63–0.74) | 0.50 | (0.32–0.80) |
| Income level (Ref = >$50K) | ||||||||
| < $50K | 0.77 | (0.72–0.83) | 0.86 | (0.82–0.90) | 0.80 | (0.74–0.86) | 1.00 | (0.76–1.31) |
| Unknown | 0.90 | (0.82–0.98) | 0.95 | (0.90–1.01) | 0.70 | (0.64–0.77) | 0.88 | (0.61–1.27) |
| Education (Ref = GED or less) | ||||||||
| Some college | 1.05 | (0.98–1.12) | 1.27 | (1.21–1.33) | 1.21 | (1.12–1.30) | 1.06 | (0.84–1.34) |
| College + | 1.19 | (1.10–1.28) | 1.42 | (1.35–1.49) | 1.72 | (1.59–1.85) | 1.02 | (0.76–1.38) |
| Marital status (Ref = Married) | ||||||||
| Not married | 0.80 | (0.73–0.89) | 0.78 | (0.73–0.83) | 0.56 | (0.53–0.61) | 1.06 | (0.84–1.34) |
| Other | 0.81 | (0.76–0.87) | 0.81 | (0.77–0.85) | 0.80 | (0.73–0.87) | 1.02 | (0.76–1.38) |
| Rural residence (Ref = Yes) | ||||||||
| No | 1.16 | (1.06–1.26) | 1.27 | (1.19–1.35) | 1.22 | (1.03–1.44) | 0.90 | (0.65–1.25) |
| Unknown | 1.08 | (1.00–1.16) | 1.12 | (1.06–1.18) | 1.29 | (1.10–1.52) | 0.96 | (0.71–1.30) |
| Last checkup (Ref = >1 year or never) | ||||||||
| <1 year ago | 3.46 | (3.22–3.72) | 2.53 | (2.40–2.67) | 2.56 | (2.40–2.72) | 2.31 | (1.54–3.46) |
| Has primary care provider (Ref = Yes) | ||||||||
| No | 0.42 | (0.38–0.46) | 0.44 | (0.41–0.47) | 0.74 | (0.69–0.79) | 0.58 | (0.39–0.88) |
| BMI (Ref = Normal) | ||||||||
| Overweight | 1.17 | (1.09–1.25) | 1.13 | (1.07–1.18) | 1.08 | (1.00–1.16) | 0.88 | (0.68–1.13) |
| Obese | 1.16 | (1.07–1.25) | 1.07 | (1.01–1.12) | 1.02 | (0.95–1.10) | 0.73 | (0.58–0.93) |
| Unknown | 1.02 | (0.91–1.14) | 0.83 | (0.76–0.91) | 1.03 | (0.93–1.14) | 0.89 | (0.56–1.41) |
| Number of chronic medical conditions (Ref = 0) | ||||||||
| 1-2 | 1.02 | (0.95–1.09) | 1.30 | (1.25–1.36) | 1.02 | (0.96–1.08) | 1.89 | (1.41–2.53) |
| 3+ | 0.88 | (0.79–0.99) | 1.69 | (1.56–1.83) | 0.94 | (0.83–1.05) | 3.72 | (2.75–5.04) |
| Smoking status (Ref = Never) | ||||||||
| Current | 0.56 | (0.51–0.60) | 0.73 | (0.69–0.77) | 1.02 | (0.95–1.10) | 0.83 | (0.67–1.04) |
| Former | 0.86 | (0.81–0.92) | 1.07 | (1.02–1.12) | 1.22 | (1.12–1.32) | Ref! | |
| Binge drinking (Ref = No) | ||||||||
| Yes | 1.02 | (0.92–1.12) | 1.00 | (0.94–1.06) | 1.15 | (1.06–1.25) | 1.25 | (0.91–1.72) |
| Unknown | 1.04 | (0.87–1.25) | 0.83 | (0.72–0.95) | 0.92 | (0.77–1.10) | 1.02 | (0.56–1.86) |
| Exercise (Ref = No) | ||||||||
| Yes | 1.37 | (1.28–1.46) | 1.19 | (1.13–1.25) | 1.32 | (1.23–1.41) | 0.84 | (0.68–1.03) |
P-value < .05 is bolded.
– indicates that this variable is not applicable for the screening type.
70-75 (not 70–79) based on screening recommendations for colorectal cancer screening.
Discussion
Overall, cancer screening rates in skin cancer and other cancer survivors were higher than non-cancer individuals, except for lung cancer screening in skin cancer survivors and breast cancer screening in other cancer survivors. Previous studies on screening rates in cancer survivors of different cancer types have varied results. While some studies have found higher rates of screening amongst survivors,18–20 other studies have found similar14,19 or lower rates of screening in certain survivors compared to non-cancer controls.21,22
Amongst studies including skin cancer survivors, Tsai et al. also used the BRFSS to report rates of colorectal cancer screening across different cancer survivors and found a 78.1% guideline-concordant colorectal cancer screening rate in skin cancer survivors. This was lower than lung, prostate, and breast cancer survivors’ rates but higher than cervical cancer survivors’ rates. No comparison was made to non-cancer controls. While the current study found a higher skin cancer survivor colorectal cancer screening rate of 82.1% compared to the 78.1% in Tsai et al. Tsai et al. limited their cohort to 2020 and used American Cancer Society screening recommendations, whereas we used a 5-year time period and used the USPSTF screening recommendations.15 Mayer et al. studied melanoma survivors’ screening rates utilizing the National Cancer Institute’s Health Information National Trends Survey I from 2002 to 2003 and found 89.7% to have ever had a mammogram for breast cancer, 93.8% to have ever had a colonoscopy or sigmoidoscopy or fecal occult blood test for colon cancer, and 98.3% to have ever had a Papanicolaou test for cervical cancer. However, the study does not evaluate whether patients are currently up-to date on screening, only if they have ever undergone screening. The incidence of these screenings when comparing cancer survivors and non-cancer patients was not significantly different after controlling for age, race and ethnicity, and health care access.14 Based on comparison with these previous reports, this study presents new evidence of high skin cancer survivor screening rates, which are comparable to other cancer survivors and higher than non-cancer controls except for lung cancer screening.
Lung cancer screening in skin cancer survivors was lower than that of other cancer survivors and no different than non-cancer individuals. This suggests that skin cancer survivors may not be adequately screened, particularly since NMSC survivors are reported to have a higher risk of lung cancer10 and thus could significantly benefit from screening. A systematic review of lung cancer screening in the general population reported a range of 12% to 91% guideline-concordant screening.23 In this context, the current study’s reported skin cancer survivor rate of 22.6% is plausible. Low rates of lung cancer screening have previously been attributed to reporting bias due to variance in individual cohort follow-up time, as well as screening availability and frequency of recommendation by providers.23 Screening in other cancer survivors is likely higher than skin cancer survivors because routine imaging for distant metastasis is standard for other cancer types but not for skin cancer, and these reasons for having chest imaging were not elucidated in the BRFSS survey.
The differences in breast and colorectal cancer screening between melanoma and NMSC survivors identified in this study are difficult to place in the context of perceptions and behaviors of these 2 cohorts since little data exists comparing them directly. One study comparing health-related quality of life in melanoma survivors versus NMSC survivors found that NMSC survivors had a higher symptom burden, but melanoma survivors had a higher psychological impact.24 In general, patients’ perceived cancer risk has been proposed as either a motivator or deterrent in undergoing screening. Patients who perceived increased benefits of screening and have fewer barriers are more likely to undergo screening.14 Other influential factors could be the frequency of follow-up for skin cancer, which may either increase screening based on the frequency of healthcare interaction or decrease screening due to healthcare fatigue.
This study found health insurance, yearly checkups, and having a primary care provider to significantly influence all types of cancer screening. Previous studies have reported these same factors to be influential.15,21,25–30 While further elucidating how age, race and ethnicity, education, chronic medical conditions, and behavioral risk factors influence screening may improve understanding, healthcare access issues such as insurance and regular visits are more likely modifiable and thus a proposed focus for providers moving forward.
Limitations include the utilization of a self-reported database. Nonetheless, prior studies have found BRFSS to be reliable, valid, and similar in reported prevalence compared to other national databases, despite significant differences in questionnaires and data collection.31–33 However, self-reporting is especially an issue in skin cancer because of patients’ inability to accurately categorize their NMSC diagnosis. For example, in a study of basal cell carcinoma (BCC) survivors, only 28% were able to identify that the lesion they had excised was BCC.34 Another study found that patients correctly identified their chart-documented history of BCC 84.3% of the time, SCC 81.5% of the time, and NMSC status 91.8% of the time. They correctly identified their history of melanoma in 94.8% of cases and their overall history of any skin cancer in 92.6% of cases. Self-reported skin cancer history of any kind had a positive predictive value of 95.1% and a negative predictive value of 85.9%.35 While our study population had over 100,000 cases who could not recall if they had NMSC or melanoma, Ming et al. study supports that patients can accurately recall a history of skin cancer with some limitation. While the relative ratio of self-reported history of melanoma to NMSC is 1:2, much higher than the prevalence of melanoma amongst skin cancers in the population, this likely reflects that patients are better at self-identifying a history of melanoma. Another limitation of survey data, aside from correctly identifying a diagnosis, is patients’ ability to correctly report their cancer screening behavior. Self-reported screening behavior is used as an endpoint for many trials promoting screening, and comparisons of health record data and patient reporting of colon cancer screening, for example, found sensitivity and specificity above 85% for all three accepted colon cancer screening modalities.36 Screening recommendations changed for cervical, colorectal, and lung cancer between 2017 and January 2024, when this analysis was performed using the most up-to-date USPSTF screening recommendations. During that time frame, the scope of patients recommended to be screened widened for all 3 of these cancer types. In this way, we likely underestimate the number of people who are up-to-date on cervical, colorectal, and lung cancer screening. Overall, this cohort of melanoma and NMSC survivors was not evenly distributed by year and thus may be skewed in its reflection of the population. Finally, screening rates in this study are impacted by the coronavirus pandemic, since BRFSS screening rates were reported to be lower in 2020 for breast, colorectal, and cervical cancer compared to prior years.37
Conclusion
Skin cancer survivors have a higher prevalence of recommendation-concordant breast, colorectal, and cervical cancer screening compared to non-cancer individuals. However, skin cancer survivors in this cohort had a low rate of lung cancer screening that was not higher than non-cancer individuals. Of skin cancer survivors, melanoma survivors had lower breast and colorectal cancer screening, whereas NMSC survivors had lower cervical cancer screening. While their risk for secondary primary malignancies is high, skin cancer survivors may be missing opportunities for preventative cancer screening. Dermatologists can educate skin cancer patients on their overall increased risk for secondary cancers and advocate for increased access to health insurance, promote routine checkups, and recommend that patients establish a primary care provider to help increase their patients’ screening adherence.
Conflicts of interest
None.
Funding sources
None.
Ethics/IRB approval status
The Office of Regulatory Affairs at University of Nebraska Medical Center determined this project does not constitute human subject research as defined at 45CFR46.102. Therefore, it does not require IRB review.
Author contributions
SK: Primarily responsible for study conception, literature review, statistical analysis planning and review, manuscript drafting, and manuscript revision. JM: Contributed to statistical analysis, statistical analysis planning and review, and manuscript revision. AW: Contributed to study conception, statistical analysis planning and review, manuscript revision, and final manuscript approval.
Patient consent
N/A.
Data availability
This study was performed using publicly available data. Data from the intermediate steps of the analysis may be available upon further request to first author.
Contributor statements
All authors contributed in the concept design and writing of this paper. J.M. ran the statistical analyses.
Prior presentations
None.
Supplementary data
Supplementary material associated with this article can be found at https://links.lww.com/IJWD/A95, https://links.lww.com/IJWD/A96, https://links.lww.com/IJWD/A97, and https://links.lww.com/IJWD/A98.
Supplementary Material
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
This study was performed using publicly available data. Data from the intermediate steps of the analysis may be available upon further request to first author.