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. Author manuscript; available in PMC: 2022 Oct 6.
Published in final edited form as: J Health Commun. 2021 Oct 6;26(8):576–585. doi: 10.1080/10810730.2021.1966686

“Let’s Talk about Skin Cancer”: Examining Association between Family Communication about Skin Cancer, Perceived Risk, and Sun Protection Behaviors

Smita C Banerjee 1, Andrew Sussman 2, Elizabeth Schofield 1, Dolores D Guest 2, Yvonne S Dailey 2, Matthew R Schwartz 2, David B Buller 3, Keith Hunley 2, Kim Kaphingst 4, Marianne Berwick 2, Jennifer L Hay 1
PMCID: PMC8513818  NIHMSID: NIHMS1736417  PMID: 34612176

Abstract

Family communication about skin cancer risk may motivate protective behaviors. However, it is unclear how widespread such communication might be. In this study we describe prevalence and patterns (across environmental, personal, and behavioral factors) of family communication about skin cancer across N=600 diverse (79% female, 48% Hispanic, 44% non-Hispanic White) primary care patients from Albuquerque, New Mexico, a geographical location with year-round sun exposure. Over half reported discussing general cancer (77%) and skin cancer risks (66%) with their families. The most frequent target of skin cancer risk communication included doctors (54%), followed by friends/co-workers (49%), spouse/partner (43%), other family members (38%), sisters (36%), mothers (36%), daughters (33%), sons (32%), father (24%), and brothers (22%). On average, participants reported having talked to three family members about skin cancer risks. The most frequently discussed content of skin cancer risk communication was use of sun protection (89%), followed by personal risk of skin cancer (68%), who had skin cancer in the family (60%), family risk of skin cancer (59%), time of sun exposure (57%), and skin cancer screening (57%). A family or personal history of cancer, higher perceived risk, higher health literacy, being non-Hispanic, having higher education or income, and proactive sun protective behavior were associated with greater family communication about general cancer and skin cancer risks. These study findings have implications for interventions that encourage discussions about skin cancer risk, sun protection, and skin cancer screening that lead to adoption of sun-safe behaviors.

Keywords: Family communication, MC1R testing, skin cancer, social cognitive theory, sun protection

Family communication about health can impact the values, attitudes and behaviors of family members (Baiocchi-Wagner & Talley, 2013; Gafner, 2018; Koerner & Schrodt, 2014; Turner & West, 2015). Across a person’s lifespan, the family is a primary and most proximal influence on the health of all members (Koerner & Schrodt, 2014). Interactions among the family members shape behavior, lifestyle, relationships, perceptions, and ultimately, health capacities and health decisions (e.g., see Turner & West, 2015). Family communication and health-related conversations may directly impact a variety of health behaviors from diet and exercise to substance use, and sexual activity (e.g., Baiocchi-Wagner & Talley, 2013; Corona, Rodríguez, Quillin, Gyure, & Bodurtha, 2013; Miller-Day, 2002; Roberts, Gerrard, Reimer, & Gibbons, 2010; Romo, Cruz, & Neilands, 2011; Zhen-Duan, Engebretsen, & Laroche, 2019). As well, family communication about cancer risk affects attitudes about cancer risk as well as cancer risk behaviors (Young et al., 2017).

In the last decade, research attention has focused on family communication about cancer risk, and in particular, communication of genetic testing results in high‐risk families (Young et al., 2017). According to Harris, Hay, Kuniyuki, Asgari, Press, and Bowen (2010), “The family provides an important communication nexus for information exchange and support about family cancer history, and for the adoption of family‐wide cancer risk reduction strategies.” (p. 1102). Whereas a good deal of the prior research on family communication about cancer has focused on genetic testing and/or communication within families of cancer survivors (e.g., Bowen, Hay, Harris-Wai, Meischke, & Burke, 2017; Harris et al., 2010; Hay, Gordon, & Li, 2015; McBride, Koehly, Sanderson, & Kaphingst, 2010; Smit et al., 2017; Wu et al., 2016, Young et al., 2017), much less is known about family communication about cancer risk in families unselected for risk status, and drawn from a wide range of demographic characteristics from the general population. In this study, we examine family communication regarding skin cancer in primary care patients living with year-round sun exposure.

Skin cancer is the most common yet preventable cancer in the United States and consists of basal cell, squamous cell, and melanoma (American Cancer Society, 2020a; Guy, Machlin, Ekwueme, & Yabroff, 2015). Approximately 9,500 people in the U.S. are diagnosed with non-melanoma skin cancer every day, with basal cell and squamous cell skin cancers affecting more than 3 million Americans a year (American Academy of Dermatology, 2017; Rogers, Weinstock, Feldman, & Coldiron, 2015). In addition, the American Cancer Society (2020b) estimates 100,350 new diagnosed melanomas and 6,850 deaths from melanoma in 2020.

Improved prognosis and survival rates of people diagnosed with melanoma and non-melanoma skin cancers are, in part, contingent upon both primary and secondary prevention efforts (Voss, Woods, Cromwell, Nelson, & Cormier, 2015), and utilization of immunotherapy and targeted therapy in melanoma treatment (Albertini, 2018; Iorgulescu, Reardon, Chiocca, & Wu, 2018; Ugurel et al., 2016). Primary prevention strategies are behaviors that inhibit UV-radiation induced malignant cellular transformation, such as increased sun-protection behaviors and eliminating indoor tanning (El Ghissassi et al., 2009; International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer, 2007); secondary prevention strategies refer to early diagnosis of disease to limit morbidity and mortality such as increased dermatologist-led screening (Conic, Cabrera, Khorana, & Gastman, 2018; Neal et al., 2015; Voss et al., 2015) and skin self-examination (Paddock et al., 2016).

Family communication about skin cancer can heighten family members’ risk perceptions, and generate decision-making conversations about prevention, treatment or management, and screening behaviors (Bowen et al., 2017; Harris et al., 2010; Loescher, Crist, & Siaki, 2009), making family communication a significant component in cancer-related health decision-making (Gaff, Galvin, & Bylund, 2010; Wiens, Wilson, Honeywell, & Etchegary, 2013). Some people who perceive themselves to be at low risk of melanoma based on their phenotype (i.e., darker skin) and adapt their sun protection behaviors accordingly could actually have higher-than-average genetic susceptibility to melanoma (Smit et al., 2017). In such families, in particular, melanoma genetic risk communication or skin cancer risk communication may be something that the family has never discussed before and may trigger different responses. In the present study, we examine baseline family communication patterns in a randomized controlled trial, “SOMBRA: Skin health Online for Melanoma: Better Risk Assessment” that examined Internet presentation of the risks and benefits of personalized genomic testing for melanoma risk versus wait-list controls who were not offered testing. The study was carried out in a general population of English- or Spanish-speaking individuals in Albuquerque, New Mexico, which experiences year-round sun exposure (see Hay et al., 2017).

Theoretical Framework

Social cognitive theory explains how people acquire and maintain certain behavioral patterns, which are dependent on environment, people and past behavior. The theory also includes the concept of self-efficacy and contends that “people’s level of motivation, affective states, and actions are based more on what they believe than on what is objectively true” (p. 2, Bandura, 1997). Family communication about skin cancer risk and prevention can trigger risk reduction behaviors, and the cumulative effects of family members modeling risk reduction behaviors can act as a positive reinforcement for continuation of behaviors. In the context of the present study, social cognitive theory (Bandura, 1997) guided our focus on a combination of environmental (family health orientation, family history of cancer), personal (perceived risk, cancer worry, health literacy, phenotype, demographic), and behavioral (skin cancer screening by a health professional, and use of clothing, hat, shade, and sunglasses when out in the sun) factors as interdependent determinants of family communication about skin cancer. This study focused on baseline variables collected as part of a longitudinal RCT study (Hay et al., 2017) in order to examine naturalistic family communication regarding skin cancer risk and prevention behaviors.

In the current study, we examined patterns of communication about cancer in general, about skin cancer, and about genetic testing with friends, family members and health professionals. We assessed rates, as well as patterns, of communication across demographics. Based on social cognitive theory, our second research question was formulated around an assessment of association between environmental (family health orientation, family history of cancer), personal (perceived risk, cancer worry, health literacy, skin phenotype, demographics), and behavioral (prior behaviors - skin cancer screening by a health professional, and use of clothing, hat, shade, and sunglasses when out in the sun) factors as determinants of family communication about skin cancer risk and genetic testing. Prior research provided us some guidance in this regard. For instance, an individual who has greater perceived risk and worry about skin cancer may be prime targets for direct-to-consumer marketing of cancer genetic tests, but little is known about whether heightened concerns about skin cancer will translate to seeking genetic risk information, engaging in more family discussions about skin cancer and genetic testing, and preventive health behaviors (see Hay, Kaphingst, Baser, Li, Hensley-Alford, & McBride, 2012). Personalized information regarding an individual’s genomic risk of developing melanoma along with risk reduction strategies (such as sun protection and skin examinations) may prompt risk-appropriate discussions about skin cancer prevention and skin screening behaviors with family and health professionals and lead to improved skin cancer prevention behaviors (Smit et al., 2017). Past research summarizes that communication about disclosure of genetic test results has been typically examined in the context of motivating other family members to pursue testing, and less on communication about preventive behaviors (Fehniger, Lin, Beattie, Joseph, & Kaplan, 2013; Gaff et al. 2007). However, it is not unreasonable to purport that communication within families about genetic test results could also trigger communication about preventive behaviors. We hypothesized that a family history of cancer in combination with high family orientation, greater perceived risk, and high cancer worry would increase family communication around skin cancer risk and genetic testing. The influence of health literacy, skin phenotype, and different demographic factors on family communication is unknown and was explored. Finally, we examined how engagement in prior behaviors would influence family communication about skin cancer risk and genetic testing.

Methods

Participants

The current study was conducted in a general population in Albuquerque, New Mexico. Participants were eligible for the study if they had been registered in any University of New Mexico (UNM) clinic for at least six months, had a primary care physician in the UNM system, were aged ≥18 years, and were fluent in English or Spanish. A total of six hundred people were recruited. Of 600 participants who consented to the study, 599 answered one or both of the family communication items and were thus included in this analysis.

Procedures

The data for these analyses are drawn from a randomized controlled trial, “SOMBRA: Skin Health Online for Melanoma: Better Risk Assessment,” that examined Internet presentation of the risks and benefits of personalized genomic testing for melanoma risk versus wait-list controls who were not offered testing (Hay et al., 2017). The study was funded by the National Cancer Institute and included multiple steps, outlined in the published protocol (Hay et al., 2017). After recruitment, participants completed a survey in-clinic. This analysis is aimed at examining the naturalistic ways in which family communication around genetic testing and skin cancer risk occurred in this population. The survey occurred after recruitment and before randomization to the overall trial.

Measures

The following measures were included in the study. Family health orientation, family history of cancer (environmental factors); perceived risk, cancer worry, health literacy, skin phenotype, demographics (personal factors); prior behaviors - skin cancer screening by a health professional, and use of clothing, hat, shade, and sunglasses when out in the sun (behavioral factors); and general cancer risk communication, skin cancer risk communication, targets of skin cancer risk communication, content of skin cancer risk communication, and genetic testing communication (family communication factors).

Family health orientation.

Family health orientation was assessed via social influences on health information seeking and behavior change (Hay et al., 2012) and included four items scored on a 7-point Likert scale with response options from 1 (strongly disagree) to 7 (strongly agree) and a fourth item on a 7-point Likert-type scale from 1 (not at all motivated) to 7 (strongly motivated). The scores on the four items were summed, and a higher score indicated stronger family health orientation towards a healthy lifestyle. Cronbach’s alpha for family health orientation was 0.70 in this sample.

Perceived risk.

Perceived risk was assessed with two items. One item assessed absolute risk likelihood rated on a 2-point scale, either “likely” or “unlikely.” The second item assessed comparative risk likelihood on a 5-point scale from “well below average” to “well above average” (Weinstein, 1982). A higher score on either item indicated greater perceived risk.

Skin cancer worry.

We examined skin cancer worry in the past two weeks with a 4-point Likert-type scale from “rarely or never” to “all the time” (Lerman, Trock, Rimer, Jepson, Brody, & Boyce, 1991), and concern about developing skin cancer within the past two weeks on a 4-point scale from “not at all concerned” to “very concerned.” A higher score on the sum of these two items (range = 2 – 8) indicated higher skin cancer worry.

Health literacy.

Health literacy was assessed using three self-reported items that asked about level of confidence in filling out medical forms, frequency of needing assistance reading hospital materials, and frequency of problems learning about medical conditions (Chew, Bradley, & Boyko, 2004; Chew et al., 2008). Participants responded to the items on five-point Likert-type scales. The scores on the three items were summed and a higher score indicated higher health literacy. Cronbach’s alpha for health literacy was 0.71 in the current sample.

Skin phenotype.

Skin phenotype included self-reported tannability measured by ability and extent to which participants receive a suntan after repeated and prolonged exposure to sunlight on a 4-point scale which was dichotomized for analysis as either “very brown and deeply tanned” or “moderately tanned” versus “only mildly tanned due to a tendency to peel” or “only freckled or no suntan.” Phenotype also included burnability measured by severity and tendency to sunburn if not wearing sunscreen lotion with skin exposed to one hour of strong sunlight for the first time in the summer; this was similarly measured on a 4-point scale which we dichotomized as “get a severe sunburn with blistering” or “have a painful sunburn for a few days followed by peeling” versus “get mildly burned followed by some degree of tanning” or “get brown without any sunburn” (Gandini et al. 2005).

Demographics.

Demographics included self-reported race, ethnicity, gender, education, age, country of birth, marital status, employment status, and annual income (see Table 1).

Table 1.

Baseline Family Communication (N = 599)

Mean (SD) 1 = Not at all % 2 = A little % 3 = Some % 4 = A lot % 5 = N/A, %
About general cancer risk 2.54 (1.1) 23 24 30 23 <1
About skin cancer risk 2.27 (1.1) 34 22 27 17 <1
Spoken with …
 Doctors 1.97 (1.1) 46 21 23 10 -
 Spouse/partner 1.86 (1.1) 57 12 19 12 -
 Mother 1.68 (1.0) 64 14 11 11 -
 Father 1.45 (0.9) 76 10 6 8 -
 Brothers 1.41 (0.9) 78 9 7 6 -
 Sisters 1.66 (1.0) 64 15 13 9 -
 Sons 1.67 (1.1) 68 9 11 12 -
 Daughters 1.67 (1.1) 67 11 11 12 -
 Other family members 1.70 (1.0) 62 14 16 8 -
 Friends/ coworkers 1.88 (1.0) 51 18 23 8 -
 MAX rating across all family members 2.89 (1.1)
Spoken about …, %
 Who had skin cancer in family 60
 Personal risk of skin cancer 68
 Family risk of skin cancer 59
 Time of sun exposure 57
 Use of sun protection 89
 Skin cancer screening 57
 Other 11
 COUNT of issues, Mean (SD) 4.01 (1.7)
Spoken to family about genetic testing, % 4
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Personal/family history of cancer.

Personal history of skin cancer and family history of any cancer were examined by two single self-reported items with dichotomous options.

Skin cancer screening by a health professional.

Skin cancer screening was measured by a single item that asked participants if they had ever had their skin checked from head to toe by a health professional, with answer options as “yes” or “no.”

Sun protection behaviors.

Sun protection behaviors were measured by assessing frequency of sunscreen use, wearing a shirt with sleeves that covers shoulders, hat use, shade/umbrella use, and use of sunglasses on a 5-point Likert-type scale by asking participants whether they engage in these behaviors “never,” “rarely,” “sometimes,” “often,” or “always” during the summer or on a warm sunny day (Glanz et al., 2008). As a primary outcome, we operationalized adequate sun protection as regular (“often” or “always”) use of sunscreen in conjunction with regular use (“often” or “always”) of at least one additional sun protection strategy, consistent with a recommended combined approach to sun protection (U.S. Department of Health and Human Services, 2014).

Cancer communication variables, listed below, were derived from prior genetic communication research (Hay, et al., 2012; Ersig, Williams, Hadley, & Koehly, 2008; Hay, et al., 2009; Hay, et al., 2005).

General cancer risk communication.

General cancer risk communication was measured with one item asking about how much participants had talked about cancer risk, in general, with their family with 4-point Likert type response options ranging from 1 (“not at all”) to 4 (“a lot”). General cancer risk communication was then dichotomized to any versus none (not at all) for reporting proportions.

Skin cancer risk communication.

Skin cancer risk communication was measured with one item asking about how much participants had talked about skin cancer risk with their family with 4-point Likert type response options ranging from 1 (“not at all”) to 4 (“a lot”). Skin cancer risk communication was dichotomized to any versus none.

Targets of skin cancer risk communication.

Participants were asked to select how much they had talked with the following people about skin cancer risk with 4-point Likert type response options ranging from “not at all” to “a lot”: doctors, spouse/partner, mother, father, brothers, sisters, sons, daughters, other family members, friends/co-workers. For each participant, we calculated the maximum rating (representing the most communication) among all family members.

Content of skin cancer risk communication.

For participants who responded that they had even a little conversation with any of the aforementioned targets were asked to respond (yes/no) if their conversation covered the following topics: who had skin cancer in your family, your own risk of getting skin cancer, your family’s risk for skin cancer, what time of day you should avoid sun exposure, using sun protection, including sunscreen and protective clothing, going to the doctor to get checked for skin cancer, and anything else. For each participant we calculated the count of topics with an affirmative response, representing a breadth of topics.

Genetic testing communication.

Genetic testing communication was measured with one item asking if the participants had ever talked to their family about genetic testing for skin cancer, with dichotomous (yes/no) responses.

Data Analysis

We first used descriptive statistics (means and percentages) to summarize the extent to which participants communicated with a variety of targets (i.e., doctors, family members, and other friends or coworkers) and about a variety of topics at baseline. Next, we assessed correlates of family communication about general cancer risk and skin cancer risk; bivariate associations between each family communication item (i.e., general cancer risk and skin cancer risk) and each of the environmental, personal, and behavioral factors was assessed in a separate linear regression model. Significant correlates were then used as candidate variables to build an adjusted model via backwards model building with selection criteria based on minimizing the corrected Akaike Information Criteria (AICC). Model selection using AICC optimizes model fit to the data, with a penalty for the number of parameters (i.e., predictors) included. Thus, it is possible for a variable that was not significant to be retained in the final model. Type I error rates were set at 0.05 and statistical analyses were conducted in SAS version 9.4 (Cary, NC).

Results

Overall, the sample was 79% female, 48% Hispanic, 44% non-Hispanic White, and 76% had more than a high school education. Ages ranged from 19 to 85; average age was 54 years old. Most (91%) of participants were born in the US. Half (46%) of participants were currently employed, with another quarter (23%) retired. Few (16%) participants had a personal cancer history, though one-third (34%) had a family history of any cancer. Full demographics have been previously reported (Christian, et al., Under Review, 2020).

Rates and Patterns of Family Communication about Cancer Risk

A large number of participants reported having previously discussed general cancer risk (77%) and skin cancer risk (66%) with their families. Mean scores for general cancer risk and skin cancer risk communication were 2.54 and 2.27 (on 1–4 scales), respectively, falling between “a little” and “some.” The two family communication items were strongly correlated (r=0.69, p<.001). About a quarter, 23%, had talked with their family about cancer risk “a lot,” 17% had talked about skin cancer risk “a lot.”

Participants reported having spoken with a variety of family members and non-relatives and about a variety of cancer risk topics. The most frequent target of skin cancer risk communication was doctors (54%), followed by friends/co-workers (49%), spouse/partner (43%), other family members (38%), sisters (36%), mothers (36%), daughters (33%), sons (32%), father (24%), and finally brothers (22%). On average, participants reported having talked to approximately three categories of family members about risks for skin cancer. The most frequently discussed content of skin cancer risk communication was use of sun protection (89%), followed by personal risk of skin cancer (68%), who had skin cancer in the family (60%), family risk of skin cancer (59%), time of sun exposure (57%), skin cancer screening (57%), and other (11%). Overall, participants reported having discussed an average of 4 topics related to skin cancer risk with family, friends, and doctors. Finally, only 4% of participants had spoken to family members about genetic testing, so this item was not included in further analyses due to the small sample size. Table 1 gives full details of baseline family communication.

Examining Correlates of General Cancer Risk and Skin Cancer Risk Communication

As shown in Table 2, a family or personal history of cancer (M= 2.91 vs. 2.47, p<.001 ), higher perceived risk (comparative b=0.25, p<.001; absolute b=0.17, p<.001), higher health literacy (b=0.05, p=.009), being non-Hispanic (M=2.64 vs. 2.44, p=.002), having more than a high school education (M=2.62 vs. 2.26, p=.001), having higher income (M=2.65 vs. 2.38, p=.002), and proactive sun protective behavior (total count b=0.19, p<.001) were associated with more family communication about general cancer risk in unadjusted models.

Table 2.

Baseline characteristics and unadjusted associations to baseline family communications about cancer (general) and skin cancer (N = 599)

General Cancer Risk Skin Cancer Risk
n Mean (SD) Range b (SE) p-value b (SE) p-value
Environmental Factors
 Family Health Orientation 598 22.32 (4.87) 4 – 28 0.02 (0.01) 0.069 0.02 (0.01) 0.061
 Family Cancer History 583 35% 0.49 (0.09) <.001 0.78 (0.09) <.001
Personal Factors
 Absolute Perceived Risk, Likely (%) 390 49% 0.43 (0.11) <.001 0.69 (0.11) <.001
 Comparative Perceived Risk 589 2.87 (0.97) 1 – 5 0.25 (0.04) <.001 0.32 (0.05) <.001
 Absolute Perceived Risk 538 3.95 (1.44) 1 – 7 0.17 (0.03) <.001 0.22 (0.03) <.001
 Worry 594 2.54 (1.07) 2 – 8 0.08 (0.04) 0.051 0.12 (0.04) 0.005
 Health Literacy 595 10.59 (2.13) 0 – 12 0.05 (0.02) 0.009 0.06 (0.02) 0.003
 Burnability, Yes (%) 568 40% 0.17 (0.09) 0.061 0.26 (0.09) 0.006
 Tannability, Yes (%) 536 73% −0.02 (0.10) 0.835 −0.09 (0.11) 0.407
 Race/ Ethnicity (%)
  Hispanic 48% −0.28 (0.09) 0.002 −0.54 (0.09) <.001
  White, not Hispanic 44% REF REF
  All Other 8% −0.54 (0.17) 0.001 −0.67 (-0.17) <.001
 Gender, Male (%) 599 21% −0.04 (0.11) 0.680 −0.09 (0.11) 0.410
 Education, >HS (%) 599 77% 0.36 (0.10) 0.001 0.47 (0.11) <.001
 Age, >55 (%) 591 52% −0.07 (0.09) 0.417 −0.05 (0.09) 0.553
 Income, >$30k (%) 594 58% 0.27 (0.09) 0.002 0.31 (0.09) 0.001
 Personal Cancer History, Yes (%) 595 16% 0.44 (0.12) <.001 0.30 (0.12) 0.015
Behavioral Factors
 Screened by Professional, Yes (%) 597 37% 0.50 (0.09) <.001 0.72 (0.09) <.001
 Sunscreen Use 599 3.17 (1.34) 1 – 5 0.16 (0.03) <.001 0.22 (0.03) <.001
 Sleeves Use 598 3.79 (1.17) 1 – 5 0.06 (0.04) 0.105 0.05 (0.04) 0.161
 Hat Use 598 2.81 (1.38) 1 – 5 0.09 (0.03) 0.004 0.14 (0.03) <.001
 Shade Use 598 3.49 (1.03) 1 – 5 0.14 (0.04) 0.001 0.19 (0.04) <.001
 Sunglass Use 598 3.83 (1.40) 1 – 5 0.12 (0.03) <.001 0.15 (0.03) <.001
 Sunscreen +1 599 44% 0.33 (0.09) <.001 0.55 (0.09) <.001
 Count of Often/Always 597 2.68 (1.32) 0 – 5 0.19 (0.03) <.001 0.25 (0.03) <.001
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All of the significant correlates for general cancer risk communication (i.e., family or personal history of cancer, higher perceived risk, higher health literacy, being non-Hispanic, having higher education or income, and proactive sun protective behavior), as well as greater skin cancer worry and burnability, were associated with more skin cancer family communication. Participants who were Non-Hispanic Whites (M = 2.48 vs. 2.04, p<.001), and with a personal history of cancer (M = 2.53 vs. 2.22, p=.015) had more frequent conversations with family members about skin cancer risk as compared to those who were Hispanic, and with no personal history of cancer, respectively. Further, greater skin cancer worry (β=0.12, p=0.005) and greater burnability (β=0.26, p=0.006) were both associated with more skin cancer family communication. Table 2 provides an overview of differences in family communication measures by environmental, personal, and behavioral factors.

Separate adjusted models were built for each family communication item and are given in Table 3. For the adjusted general cancer risk model, family (p=0.04) and personal cancer history (p=0.03), perceived risk (p=0.003), annual household income over $30,000 (p=0.04), having had a previous skin check (p<0.001), and more sun protective behavior (p<0.001) were all significantly associated with more family communication. For the adjusted skin cancer risk model, family cancer history (p<0.001), perceived risk (p<0.001), having had a previous skin check (p<0.001), and more sun protective behavior (p<0.001) were significantly associated with more family communication.

Table 3.

Adjusted associations to baseline family communications about cancer (general) and skin cancer

General Cancer Risk n = 516 Skin Cancer Risk n = 519
b (SE) p-value b (SE) p-value
Environmental Factors
 Family Cancer History 0.20 (0.10) 0.044 0.49 (0.09) <.001
Personal Factors
 Absolute Perceived Risk 0.10 (0.03) 0.003 0.11 (0.03) 0.001
 Worry NA -
 Health Literacy - -
 Burnability, Yes (%) NA -
 Race/Ethnicity - -
 Education, >HS (%) - -
 Income, >$30k (%) 0.19 (0.09) 0.043 0.14 (0.09) 0.102
 Personal Cancer History, Yes (%) 0.27 (0.12) 0.032 -
Behavioral Factors
 Screened by Professional, Yes (%) 0.32 (0.10) 0.001 0.51 (0.09) <.001
 Count of Often/Always 0.14 (0.03) <.001 0.16 (0.03) <.001
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Note that these two final models were built using backwards regression and AICC selection criteria. Worry and burnability were not candidate variables in the general cancer risk model. Variables with a dash (-) were removed during the model building process due to AICC selection criteria.

Discussion

We examined family communication patterns around cancer risk, skin cancer risk, and genetic testing among in a general population sample in Albuquerque, New Mexico. To our knowledge, this is one of the first studies evaluating skin cancer risk discussions reported by individuals drawn from a general population. Prior studies have examined skin cancer risk and prevention-related communication in families of melanoma survivors (see Azzarello, Dessureault, & Jacobsen, 2006; Bowen et al., 2017; Harris et al., 2010; Loescher et al., 2009; Rodriguez, Berwick, & Hay, 2017).

The results of the current study indicate that a relatively high proportion of participants reported having discussions regarding general cancer risk (77%) and skin cancer risk (66%) with their families, including discussions with spouse/partner, sisters, mother, daughters, sons, father, brothers, and other family members. Given that the majority of the sample were females, there could be a “gendered” reason for an overall high proportion of participants having discussions regarding general cancer risk and skin cancer risk; albeit the sex of the participant was not significant in subsequent analyses. Over half of all participants reported talking to doctors and friends/coworkers about skin cancer risk. The role of physicians is not surprising, given they provide medical care for which skin cancer prevention and treatment is relevant. However, it was a bit surprising that people spoke to friends/coworkers slightly more than to spouses. Part of this might stem from not all participants having a spouse. Combining the remaining family members showed that participants talked a lot with family members. Still, it is notable that considerable discussion of skin cancer risk occurred outside the family. This might occur because people are comfortable discussing health topics with friends, especially close friends. Coworkers may be part of the conversations about skin cancer risk because of the frequency with which participants interact with people at work and possibly the long-standing relationships built over many years of employment at the same job. Encouraging and ensuring accuracy in such conversations may have an important role in family interventions to reduce skin cancer risk within wide social networks. A qualitative approach to examining sequence and content of discussions with doctors followed by conversations with family and friends/coworkers will help clarify if people tend to engage in replication (i.e., share the same information transmitted by their doctor to family and friends/coworkers) or extension (i.e., presenting information to family and friends/coworkers that is in the same category as the topic of discussion with their doctor, such as talking about sun protection when the conversation with the doctor centered around genetic testing for skin cancer, but not the exact same information; Lee, 2018). These conversations may have differential effects on attitudes, intentions, and behavioral outcomes (Southwell, 2013).

The most frequently discussed content of skin cancer risk communication was use of sun protection followed by personal risk of skin cancer. Although New Mexico’s desert climate and high elevation contribute to increased levels of solar UV exposure, and higher overall skin cancer incidence rates (New Mexico Department of Health, 2020), there is a relatively high awareness of skin cancer risk and prevention among the general population in Albuquerque, New Mexico. However, it may be less disclosive of personal health information to discuss sun protection practices rather than personal risk for skin cancer, leading to more willingness to discuss this topic. Prevention discussions were framed around sun protection and skin cancer screening, with a small proportion of participants reporting discussions around genetic testing. Prior research (Peterson, et al., 2018) indicates that while cancer-related genetic testing could increase people’s intentions to engage in healthier behaviors, this motivation most often fails to translate into actual behavior change (Covolo, Rubinelli, Ceretti, & Gelatt, 2015). People also may in general have less specific knowledge of or experience with genetic testing, but more have had a clinical skin examination in this high solar UV environment. More research is needed to examine if communication with family, friends, and/or doctors translates into meaningful cancer prevention behaviors, particularly, skin cancer prevention.

Multivariate analyses demonstrated that family cancer history, perceived risk, having had a previous skin check, and more sun protective behaviors were associated with more family communication with regards to both general cancer and skin cancer risks. Few participants reported family communication about genetic testing. From a social cognitive theory perspective (Bandura, 1997), the associations between environmental (family history of cancer), personal (perceived risk), and behavioral factors (skin cancer screening by a health professional, and use of clothing, hat, shade, and sunglasses when out in the sun) functioned together to influence family communication about general and skin cancer. The variables associated with increased communication include those related to cancer risk and cancer risk awareness.

Interestingly, health literacy was not associated with more family communication with regards to both general cancer and skin cancer risks. Prior research has examined inadequate health literacy and poor physician-patient communication as major health-care challenges (Amalraj Starkweather, Nguyen, & Naeim, 2009). However, given that the study was done in a sample of the general population and unknown skin cancer risk, health literacy did not impact family communication. It would be interesting to assess the quality of family communication about general cancer and skin cancer risks between those with low and high health literacy to identify targets of communication interventions or campaigns.

This study has implications for skin cancer prevention interventions. Our study indicated that prevention discussions were framed around sun protection and skin cancer screening, with a small proportion of participants reporting discussions around genetic testing. Interventions or campaigns that focus on the significance and perceived utility of genetic testing can help in making genetic testing more familiar to the populations as well as spur an interest in gathering additional information about it. Interventions that improve understanding about personal and family cancer risk will be promising, and providing individualized and personalized risk information may encourage people to learn more, empower them with information to be used in communication with others and increase self-efficacy to engage in prevention behaviors (Southwell & Yzer, 2009). Meta analyses on intervention- or mass-media campaign-generated conversations indicate that such conversations have a positive effect on inducing campaign-targeted outcomes (OR=1.28) and this effect is moderated by health topic addressed by the intervention/campaign, the type of outcome being targeted by the campaign, and with whom people converse, along with several other campaign-relevant and study-relevant variables (Jeong & Bae, 2018). Interventions could potentially utilize family communication as a dissemination platform to spread skin cancer risk information and motivate sun protection practices by family members, friends, and possibly coworkers through this informal communication, improving and amplifying downstream effects on knowledge and protective behavior via social influence and modeling. Whether information about genetic testing motivates participants to discuss genetic testing with family members and friends needs to be further explored. Finally, those with lower incomes reported less frequent communication about general cancer risk, indicating that medically underserved groups may need additional support for family communication about these topics. It’s important to note that this study utilized baseline data from the SOMBRA trial (Hay et al., 2017) and does not focus on impact of genetic testing interventions.

Limitations of the Study

This study utilized cross-sectional survey data to examine pathways of association, which limits the causal interpretation of results. Given the cross-sectional nature of the data, some of the associations observed in the study could be bidirectional in nature. For instance, on one hand, conversations around sun-protection and skin cancer screening can prompt safe sun behaviors; conversely, engaging in safe sun behaviors can prompt conversations about sun-protection and skin cancer screening. Second, while this sample was highly diverse, the study was conducted with the general population of Albuquerque, New Mexico, and it is not known if the results would be generalizable to other populations outside of this region. Additionally, New Mexico has high solar UV levels relative to some parts of the United States, which may prime their residents to be more aware of skin cancer risk, and therefore more likely to engage in communication with family and friends. Third, we did not collect detailed information on communication targets and content for discussion regarding general cancer risk. It is possible that norms around sun protection behaviors dictate heightened awareness, risk, and prevention behaviors, and should have been included in the analyses.

Despite these limitations, this study adds to the growing body of literature on understanding the associations between risk perceptions, family history of cancer and communication with family, friends, and doctors about skin cancer prevention. The sample examined in the study was highly diverse in terms of racial/ethnic subgroup. Importantly, family communication about cancer, and skin cancer specifically, appears to be a frequently conducted in primary care patients in this year-round sun exposure setting, and communications were conducted with multiple targets with content relating to methods to reduce skin cancer risk. Interventions to further increase and specify such useful family interactions may be highly promising efforts to enhance cancer prevention and control in such settings.

Acknowledgements

Financial support for this study was provided by a grant from the National Institutes of Health, NIH R01 CA181241 to Jennifer Hay and Marianne Berwick (MPIs). Additionally, this research was partially supported by UNM Comprehensive Cancer Center Support Grant NCI P30CA118100 and the Behavioral Measurement and Population Sciences shared resource. We also acknowledge the MSK Support/Core Grant (NCI P30CA008748). Finally, we thank Ms. Fiona Puccio for her administrative help in completing the manuscript. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, writing, and publishing the report.

Footnotes

Declaration of Interest Statement

The Authors declare that there are no conflicts of interest.

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