Abstract
Purpose
To obtain preliminary evidence on the effect of a skin cancer prevention video for adult solid organ transplant recipients (SOTR) and informational brochures on outcomes of skin cancer knowledge, beliefs, prevention and detection behaviors, and personal agency (self-confidence/personal control) for behaviors.
Background
SOTR have a high risk of skin cancer potentiated by life-long immunosuppressive therapy posttransplantation. Skin cancer in SOTR is aggressive and difficult to treat. Prevention and early detection are important for reducing risk and improving skin cancer outcomes, but methods to inform SOTR about their risk are understudied.
Methods
A brief, evidence-based skin cancer informational video tailored to SOTR was evaluated using a quasi-experimental design that compared the outcome variables in two groups of SOTR seen in 4 transplantation clinics within 4–6 weeks posttransplantation. The video/brochure group (VBG) viewed the video once and received skin cancer information brochures. The brochure group (BG) received brochures only. Participants completed a survey on sun protection behavior (6 items; alpha = 0.75), personal agency (6 items; alpha = 0.64), beliefs (6 items; alpha = 0.60), skin cancer knowledge (6 items), and skin self-examination (SSE; 1 item) at baseline and 3 months postintervention. Data were analyzed using descriptive statistics and 2 × 2 analysis of variance.
Results
Of 113 participants, 90 completed both surveys (VBG, n = 46; BG, n = 44). Both groups had a significant increase in sun protective behavior (P < .001), skin cancer knowledge (P < .001), beliefs (P = .003), and personal agency (P = .003). There was no effect of either intervention on SSE.
Conclusion
Both interventions effectively informed SOTR about skin cancer and sun protection, promoted favorable beliefs, and improved personal agency, but were not differentially effective, suggesting that the addition of the video may not be necessary or that the video may need to be viewed more than once. More in-depth SSE teaching strategies may be necessary.
Skin cancer is the most frequently occurring cancer in solid organ transplant recipients (SOTR).1 Skin cancer in SOTR is aggressive and difficult to treat; thus, prevention and early detection potentially reduce risk and improve skin cancer outcomes.2 Prevention focuses on sun protection.3 For detection, SOTR should have a full body clinical skin examination at least yearly4–6 and do skin self-examination (SSE) monthly.7 There are few studies of skin cancer prevention and detection information delivery for SOTR. Existing studies have used print and verbal information interventions,8,9 which may not sustain skin cancer knowledge, attitudes, and behaviors.8,10 Interventions such as video have not been studied in SOTR, yet transplantation experts have suggested that video is an important messaging strategy.7
The purpose of this study was to obtain preliminary evidence on the effect of a skin cancer prevention video tailored to adult SOTR and informational brochures on outcomes of skin cancer knowledge, beliefs, prevention and detection behaviors, and personal agency (self-confidence/personal control) for behaviors. Subjects in a video brochure group (VBG) viewed the video once and received 3 skin cancer informational brochures. Subjects in a brochure group (BG) received the brochures only.
METHODS
The University of Arizona (UA) Human Subjects Protection Committee approved the study. Recruitment and data collection occurred at 4 UA transplantation clinics (heart, kidney–pancreas, liver, and lung). SOTR in these clinics typically received minimal skin cancer information. We used a quasi-experimental design, with subjects from the 4 clinics receiving the same condition during the same period to avoid contamination. Each clinic used both conditions but in different random orders. Eligible SOTR were men and women, age ≥18 years, English literate, of any race or ethnicity, who were within 4–6 weeks of their first organ transplantation and seen as an outpatient. Transplant coordinators informed eligible patients about the study. Interested SOTR then met with the study coordinator, signed consents, completed survey 1, and received the intervention in the clinic setting.
To develop the 10-minute video, Skin Cancer: Know Your Risk After Transplant, 3 UA skin cancer experts and 1 SOTR with skin cancer reached consensus to include skin cancer incidence, mortality and risk factors specific to SOTR, sun protection, and skin examination. The experts also agreed on the video storyboard and suggestions for testimonials. UA technology experts provided pre-and postproduction services. Before implementation, the video underwent formative evaluation by dermatology and transplant specialists. The brochures, published by the UA Skin Cancer Institute, are written at a 6th-grade reading level and contain appealing colors, graphics, and photographs. The Sunscreen and Sunblock Facts brochure describes rationale for sun product use, choice, and application. Skin Cancer: What Does it Look Like describes skin cancer recognition and SSE. These brochures were tested previously for content and visual appeal. A third brochure developed by the expert panel, covered skin cancer incidence, mortality, and risk factors specific to SOTR.
All subjects completed baseline survey 1 on sun protection behavior (6 items; alpha = 0.75), personal agency (6 items; alpha = 0.64), beliefs (6 items; alpha = 0.60), skin cancer knowledge (6 items), and SSE (1 item). Subjects in the VBG then viewed the video using a portable DVD player with headphones while waiting to see their healthcare provider. They received the brochures after viewing the video. BG subjects received the brochures after completing survey 1. All subjects completed the same survey 3 months postintervention (survey 2). Data were analyzed using descriptive statistics and 2 × 2 repeated measures analysis of variance (ANOVA) using SPSS v.20.11 The first factor was the intervention group (2 levels: VBG, BG). The second factor was time (baseline, 3 months). Time by group interaction was used to detect differential intervention effects, that is, if the change from baseline to 3 months differed between the groups. P < .05 were considered significant.
RESULTS
Table 1 lists the baseline characteristics of the 113 subjects enrolled. Of those, 90 completed both surveys (80% response rate; VBG, n = 46; BG, n = 44). The sample mean age was 51.5 years (SD = 14.24). There were no differences in demographic characteristics between completers and noncompleters of survey 2. The majority (83%) had undergone kidney transplantation. Based on ANOVA results (n = 90), both the VBG and the BG showed improved sun protective behavior (P < .001), skin cancer knowledge (P < .001), beliefs (P = .003), and personal agency (P = .003). There was a trend toward a differential intervention effect (ie, an interaction) for sun protective behavior (P = .087) and knowledge (P = .054). There was no effect of either intervention on SSE.
Table 1.
Comparison of the Characteristics of the Two Intervention Groups at Enrollment (n = 113)
| Characteristic | Video + Brochure Group (n = 54)
|
Brochure Group (n = 59)
|
||
|---|---|---|---|---|
| n | Percent Within Group | n | Percent Within Group | |
| Gender | ||||
| Male | 36 | 66.7 | 36 | 61.0 |
| Female | 18 | 33.3 | 23 | 39.0 |
| Education | ||||
| Grade school | 4 | 7.4 | 7 | 11.9 |
| Some high school/GED | 16 | 29.6 | 13 | 22.0 |
| Technical school/some college | 21 | 38.9 | 19 | 32.2 |
| Associate degree | 3 | 5.6 | 7 | 11.9 |
| Bachelors degree | 8 | 14.8 | 5 | 8.5 |
| Graduate degree | 2 | 3.7 | 8 | 13.6 |
| Race | ||||
| White | 28 | 51.9 | 32 | 54.2 |
| American Indian | 3 | 5.6 | 6 | 10.2 |
| African American | 2 | 3.7 | 4 | 6.8 |
| Asian | 3 | 5.6 | 1 | 1.7 |
| More than one race | 5 | 9.3 | 6 | 10.2 |
| Unknown/other | 13 | 24 | 10 | 17.0 |
| Ethnicity | ||||
| Non-Hispanic | 27 | 51.9 | 40 | 67.8 |
| Hispanic/Latino | 23 | 44.2 | 18 | 30.5 |
| Unknown | 2 | 3.8 | 1 | 1.7 |
| Skin cancer risk factors | ||||
| Blue/green/hazel/gray eyes | 15 | 27.8 | 27 | 45.7 |
| Sunburns easily | 10 | 18.5 | 11 | 18.6 |
| Blonde/red hair | 0 | 0 | 15 | 25.4 |
| >50 moles | 6 | 11.1 | 2 | 3.4 |
| >50 freckles | 4 | 7.4 | 3 | 5.1 |
DISCUSSION
Informing SOTR about their personal increased risk of skin cancer and methods to lower their risk are important, yet the best methods to accomplish these goals are unknown. Our preliminary findings show that video/brochure and brochure-only interventions effectively improve short-term skin cancer knowledge, sun protection behavior, favorable beliefs, and personal agency in recently transplanted SOTR. Other similar studies have used print or verbal information as interventions. Clowers-Webb et al8 did not find improvement in skin cancer knowledge (time since transplant unknown) 3–9 months after routine standard verbal and print skin cancer education versus repetitive print information plus the routine education. However, these authors noted that their transplantation program provided skin cancer information before, rather than after, transplantation.
Our finding of unimproved SSE was unanticipated, given that participants had a fairly high education level, more favorable skin cancer beliefs, and improved personal agency for SSE. This finding is consistent with results from Kim et al,12 but contradicts other reports of significantly increased SSE from baseline evaluation up to 9 months in SOTR who received printed skin cancer information and verbal advice posttransplantation.8,9 We did not assess SSE barriers such as age or vision. The video did not contain step-by-step SSE instructions (these were in the brochure), so SOTR may require more in-depth visual teaching strategies. The 1 SSE measurement item may not have been adequate to fully capture self-reported SSE. We agree with Kim et al12 that awareness of the cumulative effects of immunosuppression and skin cancer risk factors may eventually motivate SOTR to do SSE. Future research should address the type and timing of SSE instruction.
Our video/brochure and the brochure interventions were not differentially effective, suggesting that adding the video to the brochures may not be necessary or that the video may need to be viewed by SOTR more than once or that an enhanced video may be needed. Video is costly to develop and update; however, its appeal for convenience and low-literacy situations cannot be ignored.13 Using video in the clinic setting could save time if used for basic education, then followed by patient-tailored information. Additionally, a video/brochure intervention offers a variety of information approaches advocated by some authors.7,14
Our results showed that SOTR can use either intervention to effectively improve skin cancer knowledge, beliefs, prevention behaviors and personal agency early posttransplantation. In contrast, Kim et al12 stated that the first few months posttransplantation were too early for skin cancer education, given SOTRs’ concerns about new organ viability, new medications, clinical visits, and hesitation to learn about a potential new disease, especially cancer. We suggest that it is never too early to begin skin cancer education posttransplantation, particularly if SOTR have favorable beliefs about skin cancer prevention and confidence in their ability to perform protective behaviors.
We agree with others who suggested that this information be repeated for several years posttransplantation.8,9,12 Our study was limited by a small sample, short timeline, and use of 1 institution. We plan to conduct a larger study to expand the intervention to multiple transplantation sites to begin to capture the approximate 5-year period post-transplantation when most SOTRs develop skin cancer.15,16
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
References
- 1.Zwald FO, Brown M. Skin cancer in solid organ transplant recipients: advances in therapy and management: part I. Epidemiology of skin cancer in solid organ transplant recipients. J Am Acad Dermatol. 2011;65:253–261. doi: 10.1016/j.jaad.2010.11.062. [DOI] [PubMed] [Google Scholar]
- 2.CDC. Preventing skin cancer: findings of the Task Force on Community Preventive Services on reducing exposure to ultraviolet light and counseling to prevent skin cancer: recommendations of the U.S. Preventive Services Task Force. MMWR. 2003;52:1–18. [PubMed] [Google Scholar]
- 3.Harris RB, Alberts DS. Strategies for skin cancer prevention. Int J Dermatol. 2004;43:243–251. doi: 10.1111/j.1365-4632.2004.01966.x. [DOI] [PubMed] [Google Scholar]
- 4.Bouwes Bavinck JN, Euvrard S, Naldi L, et al. Keratotic skin lesions and other risk factors are associated with skin cancer in organ-transplant recipients: a case-control study in The Netherlands, United Kingdom, Germany, France, and Italy. J Invest Dermatol. 2007:1647–1656. doi: 10.1038/sj.jid.5700776. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Perera GK, Child FJ, Heaton N, et al. Skin lesions in adult liver transplant recipients: a study of 100 consecutive patients. Br J Dermatol. 2006;154:868–872. doi: 10.1111/j.1365-2133.2006.07154.x. [DOI] [PubMed] [Google Scholar]
- 6.Carroll RP, Ramsay HM, Fryer AA, et al. Incidence and prediction of nonmelanoma skin cancer post-renal transplantation: a prospective study in Queensland, Australia. Am J Kidney Dis. 2003:676–683. doi: 10.1053/ajkd.2003.50130. [DOI] [PubMed] [Google Scholar]
- 7.Lewis KG, Jellinek N, Robinson-Bostom L. Skin cancer after transplantation: a guide for the general surgeon. Surg Clin North Am. 2006;86:1257–1276. doi: 10.1016/j.suc.2006.06.007. [DOI] [PubMed] [Google Scholar]
- 8.Clowers-Webb HE, Christenson LJ, Phillips PK, et al. Educational outcomes regarding skin cancer in organ transplant recipients: Randomized intervention of intensive vs standard education. Arch Dermatol. 2006;142:712–718. doi: 10.1001/archderm.142.6.712. [DOI] [PubMed] [Google Scholar]
- 9.Firooz A, Amin-Nejad R, Bouzari N, et al. Sun protection in Iranian kidney transplant recipients: knowledge, attitude and practice. J Eur Acad Dermatol Venereol. 2007;21:754–757. doi: 10.1111/j.1468-3083.2006.02059.x. [DOI] [PubMed] [Google Scholar]
- 10.Donovan JC, Shaw JC. Compliance with sun protection following organ transplantation. Arch Dermatol. 2006;142:1232–1233. doi: 10.1001/archderm.142.9.1232. [DOI] [PubMed] [Google Scholar]
- 11.IBM. SPSS: Statistical programming for social sciences. 20. Armonk, NY: IBM; [Google Scholar]
- 12.Kim NN, Boone SL, Ortiz S, et al. Squamous cell carcinoma in solid organ transplant recipients: influences on perception of risk and optimal time to provide education. Arch Dermatol. 2009;145:1196–1197. doi: 10.1001/archdermatol.2009.247. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Avis NE, Smith KW, Link CL, et al. Increasing mammography screening among women over age 50 with a videotape intervention. Prev Med. 2004;39:498–506. doi: 10.1016/j.ypmed.2004.05.024. [DOI] [PubMed] [Google Scholar]
- 14.Partin MR, Nelson D, Flood AB, et al. Who uses decision aids? Subgroup analyses from a randomized controlled effectiveness trial of two prostate cancer screening decision support interventions. Health Expect. 2006;9:285–295. doi: 10.1111/j.1369-7625.2006.00400.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Brewer JD, Colegio OR, Phillips PK, et al. Incidence of and risk factors for skin cancer after heart transplant. Arch Dermatol. 2009;145:1391–1396. doi: 10.1001/archdermatol.2009.276. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Tessari G, Naldi L, Boschiero L, et al. Incidence and clinical predictors of a subsequent nonmelanoma skin cancer in solid organ transplant recipients with a first nonmelanoma skin cancer: a multicenter cohort study. Arch Dermatol. 2010;146:294–299. doi: 10.1001/archdermatol.2009.377. [DOI] [PubMed] [Google Scholar]