Dear Editor,
As ultraviolet radiation is a major risk factor for skin cancer development, patients are advised to regularly practice sun protection. The risk of future skin cancers can be reduced by counseling patients on sun protection behaviors.
Questionnaires can provide clinicians with feedback on patient behaviors and quantify subjective outcomes, such as health-related quality of life and satisfaction with treatment and outcomes. The FACE-Q Skin Cancer Module is a validated patient-reported outcome measure (PROM) developed for patients undergoing surgical procedures for facial skin cancer.1–3 The module consists of rating scales and descriptive checklists.1,4 Due to the importance of sun protection for skin cancer patients, the authors felt inclusion of a sun protection behavior checklist was clinically relevant.
Questionnaires that rely on patient self-reported behaviors assessing sun protection exist,5,6 but patient acceptability, quality and consistency of responses vary based on the length of time to complete items.7 Lengthy questionnaires in clinical settings may be less useful. Therefore, our goal was to develop a simple and short checklist, in line with best practices,8 to assess behaviors related to sun protection of patients presenting for facial skin cancer surgery. Items related to outdoor activities with four response options were developed from patient interviews (n=15),2 refined through expert opinion with clinicians in plastic surgery and dermatology, and pilot-tested in 5 patients.1 Subsequent field-testing among 209 patients with skin cancer demonstrated that the items did not fit the Rasch psychometric model,1 therefore we propose using the items as a checklist. The final checklist to assess behaviors related to sun protection of patients presenting for facial skin cancer surgery consists of 5 items (ranging 1= never to 4= always): generally avoid the sun (Q1); wear sunscreen (Q2); stay in the shade (Q3); wear a hat (Q4); and wear clothing in sunny weather (Q5).
Following development, we analyzed data from 531 patients (Table I) who completed the checklist at Memorial Sloan Kettering Cancer Center prior to dermatologic surgery for facial skin cancer between March 2017 and October 2018. Most patients reported some level of protection, with fewer than 3.4–10.5% answering “never” for the five items (Figure 1). The odds ratio with Bonferroni adjustment (p<0.01 considered significant) was calculated for the individual items (Table II). Women were 1.9 times more likely than men to wear sunscreen (p=0.001) and 0.5 times less likely to wear a hat (p=0.001). Although not significant, women were 1.7 times more likely than men to avoid the sun (p=0.013). Having a history of skin cancer was associated with a higher likelihood (OR 1.6–3.4) of reporting more sun protection behaviors (Q1 p=0.001, Q2 p=0.023, Q3–5 p<0.001). Patients with more than three prior skin cancers were 3.1–3.4 times more likely to seek shade (p<0.001), wear a hat (p<0.001), and cover their skin (p<0.001). Although smokers were less likely to avoid the sun and wear sunscreen than non-smokers, this difference was not significant (p=0.02, p=0.04). No significant difference was seen based on age and the type of skin cancer.
Table I.
Patient demographic and clinical factors of patients with facial skin cancer (N=531).
| Clinical/Demographics | Characteristics | N (%) |
|---|---|---|
| Gender | Female | 247 (47) |
| Male | 284 (53) | |
| Age (years) | 18–39 | 32 (6) |
| 40–64 | 210 (39) | |
| ≥ 64 | 289 (54) | |
| Marital Status | Married | 160 (30) |
| Single | 371 (70) | |
| Smoking history | Never | 307 (58) |
| Smoked | 224 (42) | |
| Skin cancer in history (N) | 0 | 233 (44) |
| 1–3 | 210 (40) | |
| ≥4 | 88 (17) | |
| Diagnosis | Keratinocyte carcinoma | 454 (86) |
| Melanoma | 68 (13) | |
| Other cutaneous malignancies | 9 (2) |
Figure 1.
Percentage of patient responses for the 5 items of the Sun Protection Behavior checklist
Table II.
Odds ratios for the individual sun protection items with gender and history of skin cancer (N=531).
| Variable | N (%) | OR (95% CI) | ||||
|---|---|---|---|---|---|---|
| Avoid sun | Sunscreen | Shade | Hat | Cover cloth | ||
| Gender | ||||||
| Male | 284 (53) | 1.0 (referent) | 1.0 (referent) | 1.0 (referent) | 1.0 (referent) | 1.0 (referent) |
| Female | 247 (47) | 1.7 (1.1 –2.5)* | 1.9 (1.3 –2.8)* | 1.1 (0.8 – 1.6) | 0.5 (0.4 –0.8)* | 0.8 (0.5 – 1.1) |
| Skin Cancer History | ||||||
| 0 | 233 (44) | 1.0 (referent) | 1.0 (referent) | 1.0 (referent) | 1.0 (referent) | 1.0 (referent) |
| 1–3 | 210 (40) | 2.1 (1.3 –3.3)* | 1.6 (1.1–2.5) | 2.5 (1.7–3.8)* | 3.4 (2.3–5.2)* | 2.2 (1.5–3.3)* |
| >3 | 88 (17) | 2.0 (1.1–3.7) | 1.0 (0.6–1.8) | 3.1 (1.7–5.6)* | 3.4 (1.9–6.0)* | 3.3 (1.9–5.7)* |
Statistically significant with a p-value of <0.01
Abbreviation: OR, Odds Ratio
The Sun Protection Behavior checklist provides the clinician with a simple and quick tool to help identify areas of improvement in sun protection and can be used to identify patterns in individuals and groups. Results of the checklist are consistent with trends reported in the literature,9,10 suggesting its potential use as triage to assess sun protection behavior during a short office visit. Future research applying the checklist in clinic, at initial and subsequent visits, may give insight into changes in patients’ sun protection behavior. Its ease of use may allow for shorter intervals between assessments, leading to rapid, real-time changes in targeted counseling over time. The checklist can be used independently or in conjunction with the scales and checklists of the FACE-Q Skin Cancer module for a comprehensive assessment of patients presenting for dermatologic surgery. The checklist is available to license at www.qportfolio.org.
Funding sources:
The National Cancer Institute of the National Institutes of Health under Award Number R25CA020449 and the National Institutes of Health/National Cancer Institute Cancer Center Support Grant P30 CA008748.
The funder had no role in the design and conduct of the study: collection, management, analysis, and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication. The FACE-Q Skin Cancer Module is owned by Memorial Sloan-Kettering Cancer Center.
Footnotes
Conflicts of interest: Anne Klassen, Stefan Cano and Andrea Pusic are co-developers of the FACE-Q and, as such, receive a share of any license revenues as royalties based on their institution’s inventor sharing policy.
References
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