Abstract
This cross-sectional study examines associations between barriers and lack of physician-based skin examinations in a population-based sample of young melanoma survivors.
More than 7000 melanomas are diagnosed annually among US adolescents and young adults (AYAs, defined as 15-39 years old at diagnosis),1 resulting in a large constituency of AYA survivors. This population is understudied and at higher risk of subsequent melanomas compared with older populations.2 Because risk remains elevated beyond 2 decades after an initial melanoma,2 annual physician-based skin examinations (PSEs) are recommended.3 Thus, suboptimal PSE adherence is a concern among AYA melanoma survivors,4 and barriers to health care and/or PSE access need identification. We examined associations between barriers and lack of PSEs in a population-based sample of young melanoma survivors.
Methods
We used the same methods as the parent Project Forward study4 for this substudy of barriers to annual PSEs among young melanoma survivors (n = 128; patients were ≤24 years old at diagnosis of stage 1 or higher melanoma in 1996-2010 and surveyed at age 18-39 years in 2015). Participants were identified with demographic and tumor characteristics from the Cancer Surveillance Program, the Surveillance, Epidemiology, and End Results Program population-based cancer registry of Los Angeles County. The California Committee for the Protection of Human Subjects and the institutional review board at the University of Southern California approved this study, and a waiver of written consent was obtained owing to minimal risk and use of outreach materials that contained elements of informed consent.
We asked participants when their last PSE occurred, as previously described,4 and what barriers to health care access they experienced in the prior year (eMethods in the Supplement). For analysis, we dichotomized responses to assess adherence to annual PSE in the prior year (yes vs no) and to reflect the presence of barriers (any vs none). Logistic regression estimated odds ratios and 95% CIs, with a priori control for confounding by diagnosis age, sex, race/ethnicity, socioeconomic status, melanoma stage, and time since diagnosis. All analyses were performed in SAS, version 9.4 (SAS Institute), and the level of significance was 2-sided α = .05.
Results
Participants had a response rate of 48%,4 and of the 128 included, most were female (78 [61%]) and 20 to 24 years old at diagnosis (82 [64%]), with 107 (84%) self-reporting as non-Hispanic White and 64 (53%) as usually seen by an oncologist (Table 1). In the past year, 46 (36%) had not received a PSE, and Hispanic participants and those with lower socioeconomic status were less likely to receive a PSE (Table 1). Overall, 30 (23%) participants identified at least 1 barrier to accessing health services in the prior year; survivors without PSE were more likely to have barriers than those with PSE (17 of 46 [40%] vs 11 of 75 [15%]; Table 2). Financial barriers were the most frequent overall in the total population (19 of 128 [15%]) and among those without PSE vs with PSE (14 of 46 [30%] vs 4 of 75 [5%]). Among the 15 participants who reported “it costs too much” (the single most-reported barrier), 10 also reported having no health insurance. After adjustment, barriers (any vs none) were associated with 3.45 times the odds of no annual PSE (95% CI, 1.32-9.00).
Table 1. Characteristics of Young Adult Survivors of Melanoma by Annual PSE Status in the Prior Yeara.
| Characteristic | No. (%) | P valuec | ||
|---|---|---|---|---|
| All | PSE statusb | |||
| Yes | No | |||
| Total | 128 | 75 | 46 | NA |
| Age at diagnosis, y | .10 | |||
| <20 | 46 (36) | 23 (31) | 21 (46) | |
| 20-24 | 82 (64) | 52 (69) | 25 (54) | |
| Sex | .23 | |||
| Female | 78 (61) | 49 (65) | 25 (54) | |
| Male | 50 (39) | 26 (35) | 21 (46) | |
| Race/ethnicity | .02 | |||
| Non-Hispanic White | 107 (84) | 69 (92) | 34 (74) | |
| Hispanic | 13 (10) | 3 (4) | 9 (20) | |
| Other | 8 (6) | 3 (4) | 3 (7) | |
| Socioeconomic status | .03 | |||
| Low/low-middle | 23 (18) | 8 (11) | 13 (28) | |
| Middle | 28 (22) | 17 (23) | 11 (24) | |
| Higher-middle/high | 77 (60) | 50 (67) | 22 (48) | |
| Melanoma stage at diagnosis | .96 | |||
| I (localized) | 111 (87) | 65 (87) | 40 (87) | |
| ≥II (regional, distant) or unknown | 17 (13) | 10 (13) | 6 (13) | |
| Years since diagnosis | .67 | |||
| 5-9 | 39 (30) | 24 (32) | 14 (30) | |
| 10-14 | 62 (48) | 38 (51) | 21 (46) | |
| 15-19 | 27 (21) | 13 (17) | 11 (24) | |
| Usual source of melanoma-related care | .01 | |||
| Dermatologist | 23 (19) | 17 (23) | 6 (13) | |
| Oncologist (pediatric or medical) | 64 (53) | 45 (60) | 19 (41) | |
| Other/not sure/missing | 34 (28) | 13 (17) | 21 (46) | |
Abbreviations: NA, not applicable; PSE, physician-based skin examinations.
Participants were diagnosed with stage 1 or higher melanoma at 24 years or younger in 1996 to 2004 in Los Angeles County and were 18 to 39 years old and 5 or more years postdiagnosis at time of survey in 2015.
Seven participants were missing information on PSE status.
As determined by χ2 test.
Table 2. Population-Based Barriers to Health Care Access Among Young Adult Survivors of Melanoma by Annual PSE Status in the Prior Yeara.
| Self-reported response | No. (%) | ||
|---|---|---|---|
| All | PSE statusb | ||
| Yes | No | ||
| Total | 128 | 75 | 46 |
| Presence of barriers | |||
| None | 96 (75) | 64 (85) | 29 (63) |
| ≥1 | 30 (23) | 11 (15) | 17 (40) |
| Types of barriers experienced in prior year | |||
| Financial or health insurance | 19 (15) | 4 (5) | 14 (30) |
| It costs too much | 15 (12) | 3 (4) | 11 (24) |
| I had no health insurance | 12 (9) | 1 (1) | 10 (22) |
| My insurance company didn’t approve a test or visit | 7 (5) | 2 (3) | 5 (11) |
| Anticipated limits and financial burden | 1 (1) | 0 | 1 (2) |
| Health system/organizational | 9 (7) | 3 (4) | 6 (13) |
| I didn’t have a doctor that I could call | 5 (4) | 2 (3) | 3 (7) |
| I didn’t know where to go | 5 (4) | 1 (1) | 4 (9) |
| I didn’t have a doctor that spoke my language | 0 | NA | NA |
| I don’t have a doctor that understands my background and values | 1 (1) | 0 | 1 (2) |
| I didn’t know how to make an appointment | 0 | NA | NA |
| Work/life | 14 (11) | 8 (11) | 6 (13) |
| I was too busy | 11 (9) | 7 (9) | 4 (9) |
| I didn’t have childcare | 3 (2) | 2 (3) | 1 (2) |
| I couldn’t leave work/school | 7 (5) | 4 (5) | 3 (7) |
| Psychosocial/other | 7 (6) | 2 (3) | 4 (9) |
| I don’t trust doctors or think they can help me at this time | 2 (2) | 0 | 2 (4) |
| I didn’t want to be reminded about my cancer experience | 2 (2) | 1 (1) | 1 (2) |
| I was worried that a problem would be discovered | 3 (2) | 2 (3) | 2 (1) |
| Anxiety | 1 (1) | 1 (1) | 0 |
| None of the above | 2 (2) | 0 | 1 (2) |
Abbreviations: NA, not applicable; PSE, physician-based skin examinations.
Participants were diagnosed with stage 1 or higher melanoma at 24 years or younger in 1996 to 2004 in Los Angeles County and were 18 to 39 years old and 5 or more years postdiagnosis at time of survey in 2015.
Seven participants were missing information on either PSE or barriers.
Discussion
Results of this cross-sectional study found that barriers to health care access were associated with increased odds of suboptimal PSE adherence among AYA melanoma survivors. Financial barriers were the most frequent, consistent with the broader AYA survivorship literature concerning health care utilization.5 Taking time off of work and/or school to obtain PSEs may be particularly difficult for AYAs, who are uniquely sensitive to financial pressures while striving for career and family goals.5 Disrupted health insurance coverage6 may also limit an AYA’s ability to engage in appropriate PSE; this is underscored in the present sample, in which reports of high cost and lack of health insurance often occurred together. Although we previously reported that AYA melanoma survivors frequently check their own skin, the comprehensiveness of these skin checks remains unclear.4 Thus, challenges to obtaining annual PSEs may place AYAs at increased risk of late detection of subsequent melanoma.
The present data were cross-sectional, which limits causal inference. Evaluation of categories of barriers was limited by sample size. However, the population-based design enhances generalizability because participants did not differ from nonparticipants4 on key demographics, in comparison with clinic-based data that may have inherent biases (eg, underrepresentation of patients not in care).
Owing to cost-related barriers, young melanoma survivors could benefit from patient navigation services addressing insurance issues and financial resources to improve access to annual PSEs. Age-appropriate interventions providing guidance on conducting thorough, monthly skin self-examinations may also mitigate potential late detection of subsequent melanomas in the presence of barriers to PSEs.
eMethods.
References
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Associated Data
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Supplementary Materials
eMethods.