Awareness, knowledge, and attitudes towards sun protection among patients with melanoma and atypical mole syndrome

Dimitra Koumaki, Marios Papadakis, Stamatoula Kouloumvakou, Konstantinos Krasagakis

Dimitra Koumaki, Department of Dermatology, University Hospital of Heraklion, Heraklion 71110, Greece

Marios Papadakis, Department of Surgery II, University of Witten-Herdecke, Wuppertal 42283, Germany

Stamatoula Kouloumvakou, Department of Internal Medicine, Agios Nikolaos General Hospital, Agios Nikolaos 72100, Greece

Konstantinos Krasagakis, Department of Dermatology, University of Crete, Heraklion 71110, Greece

Abstract BACKGROUND Patients with atypical mole syndrome (AMS) have a 3- to 20-fold higher risk of developing malignant melanoma (MM) than individuals without. The most modifiable risk factor for developing MM is the ongoing ultraviolet exposure.AIM To assess awareness, knowledge, and attitudes towards sun protection among patients with MM and AMS.METHODS From January 2020 till December 2021, a written survey was administered to patients with MM and AMS and a control group who attended a specialist mole clinic at the Dermatology Department of the University Hospital of Heraklion in Heraklion, Crete, Greece. Demographic data and photoprotective practices, knowledge, and perceived barriers were collected. Relevant statistical analyses were performed using SPSS IBM 25.RESULTS In total, 121 subjects consented and participated in the survey. Their mean age was 43.92 ± 12.55 years. There were 66 (54.4%) females and 55 (45.4%) males. Forty-seven (38.8%) patients had AMS, 26 (21.5%) had a past medical history of MM, and 48 (39.7%) attended the clinic for a full skin checkup for their naevi without having AMS or MM. Although 104 (86%) participants reported using sunscreen with the majority of them (59/121 = 48.8%) wearing sunscreen with a sun protection factor of ＞ 50, only 22 (18.2%) patients did so every day and only 20 (16.5%) all year round. Approximately 74.4% of patients recalled having received advice on how to protect their skin from sunlight, and 73% were interested in receiving education about sun protection. The most mentioned barriers in photoprotection were concerns over adequate vitamin D and lack of time.CONCLUSION Despite mentioning having received adequate education in photoprotection, adherence to photoprotection practices is suboptimal in patients with MM and AMS.

Key Words: Atypical mole syndrome; Dysplastic naevi; Malignant melanoma; Photoprotection; Skin cancer

lNTRODUCTlON

The term atypical mole syndrome (AMS) refers to people who have multiple naevi (＞ 100), including some naevi larger than 8 mm in diameter with atypical features[1,2]. Patients with AMS have a 3-20 times higher risk of developing malignant melanoma (MM) than individuals without[3-6]. The most modifiable risk factor for developing MM is ongoing ultraviolet (UV) exposure[7]. Eliminating UV exposureviaphotoprotective practices is an important strategy for reducing MM risk in patients with AMS[8-10].

Through the implementation of a written survey, our aim for this study was to assess awareness, knowledge, and attitudes toward sun protection among patients with MM, those with AMS, and a control group who attended a specialist mole clinic at the dermatology department of a tertiary hospital in Greece.

MATERlALS AND METHODS

From January 2020 through December 2021, we administered a written survey to patients who attended a specialist mole clinic at the Dermatology Department of the University Hospital of Heraklion in Heraklion, Crete, Greece. Having approached 140 patients, we obtained consent from 121 patients (a response rate of 121/140 = 86.42%). The participants completed the surveys in person, and we included all the data in our analysis.

The specialist mole clinic at the Dermatology Department of the University Hospital of Heraklion is a dedicated clinic for patients at high risk of developing skin cancer, such as those who have a past medical history (PMH) of MM, non-melanoma skin cancer, or AMS or who have received immunosuppression (e.g., transplant patients). All these patients undergo annual or biannual full skin checkups and receive photoprotection counselling.

The study was approved by the Ethics Committee of the University Hospital and all participants gave consent for inclusion in the study.

Survey contents

The written survey that we administered included basic demographic data, Fitzpatrick skin phototypes, medical histories, comorbidities, and collected information regarding awareness and knowledge of photoprotection measures and current sun-protective practices. The participants were asked to report any difficulties that discouraged them from practicing photoprotective measures. We administered the survey to patients after they received counseling on photoprotection from the dermatology outpatient mole clinic.

Table 1 Demographic and clinical characteristics of 121 patients who were included in our study

0.649 0.000 0.198 0.000 0.393 0.35 0.356 0.7444 18/121 (18)1/121 (0.8)19/121 (15.7)78/121 (64.5)23/121 (19)32/121 (26.4)22/121 (18.2)21/121 (17.4)46/121 (38)32/121 (26.4)68/121 (56.2)21/121 (17.4)79/121 (65.3)42/121 (34.7)86/121 (71.1)35/121 (28.9)76/121 (62.8)45/121 (37.2)63/121 (52.1)58/121 (47.9)7.19 ± 4.86 7/48 (14.6)0/48 (0)8/48 (16.7)28/48 (58.3)12/48 (25)23/48 (47.9)12/48 (25)7/48 (14.6)6/48 (12.5)9/48 (18.8)28/48 (58.3)11/48 (22.9)40/48 (83.3)8/48 (16.7)38/48 (79.2)10/48 (20.8)30/48 (62.5)18/48 (37.5)28/48 (58.3)20/48 (42.7)7.42 ± 4.36 5/47 (10.6)1/47 (2.1)6/47 (12.8)34/47 (72.3)6/47 (12.8)0/47 (0)2/47 (4.3)11/47 (23.4)34/47 (72.3)15/47 (31.9)25/47 (53.2)7/47 (14.9)30/47 (63.8)17/47 (36.2)31/47 (66)16/47 (34)27/47 (57.4)20/47 (42.6)24/47 (51.1)23/47 (48.9)6.87 ± 5 6/26 (23.1)0/26 (0)5/26 (19.2)16/26 (61.5)5/26 (19.2)9/26 (34.6)8/26 (30.8)3/26 (11.5)6/26 (23.1)8/26 (30.8)15/26 (57.7)3/26 (11.5)9/26 (34.6)17/26 (65.4)17/26 (65.4)9/26 (34.6)19/26 (73.1)7/26 (26.9)11/26 (42.3)15/26 (57.7)7.35 ± 5.61 Green Natural hair color, n (%)Red Blond Brown Black Number of naevimages/BZ_42_454_605_934_850.png＜ 25 naevi 25-50 naevi 50-100 naevi 100 naevi Smoking status, n (%)Current smoker No smoker Ex-smoker Sunburn before the age of 18, n (%)No Yes Leisure sun exposure, n (%)No Yes Occupational sun exposure, n (%)No Yes Significant time spent outdoors, n (%)No Yes Mean weeks of vacation spent before the age of 10 (± SD)

AMS: Atypical mole syndrome; PMH: Past medical history; MM: Malignant melanoma; SD: Standard deviation; BMI: Body mass index.

Statistical analysis

Descriptive statistics, ANOVA, Kruskal-Wallis test,ttests, and Pearson correlation tests were performed using SPSS version 25.0.

RESULTS

Demographic data

Of the 140 patients that we approached who attended the specialist mole clinic at the Dermatology Department of the University Hospital of Heraklion in Heraklion, Crete, Greece from January 2020 until December 2021, 121 consented to and participated in the study, making our response rate be 121/140. Their mean age was 43.92 ± 12.55 years. There were 66 (54.4%) females and 55 (45.4%) males. Fortyseven (38.8%) patients had AMS, 26 (21.5%) had a PMH of MM, and 48 (39.7%) attended the clinic for a full skin checkup for their naevi without having AMS or MM. The main demographic and clinical characteristics of these 121 patients are summarized in Table 1. There were no statistical differences among the three groups of patients for the following demographics and clinical characteristics: Age; gender; employment status; educational level; Fitzpatrick skin phototype; body mass index; eye and natural hair color; smoking status; leisure and occupational sun exposure; significant time spent outdoors; and mean weeks of vacation spent before the age of 10, from the ages of 11 to 18, and after the age of 18. There was a significant statistical difference among the three groups regarding history of sunburn before the age of 18 (P＜ 0.001). As expected, patients with a PMH of MM more frequently had a history of sunburn before the age of 18 than the group with AMS and the control group.

Photoprotective practices

Although 104 (86%) participants reported using sunscreen, with most of them (59/121 = 48.8%) reporting wearing sunscreen with a sun protection factor (SPF) of ＞ 50, only 22 (18.2%) patients did so every day and only 20 (16.5%) did so all year round. Of all participants, 89 (73.6%) reported wearing sunscreen only during the summer and 94 (77.7%) only in direct sunny weather. Fifty-two patients reported reapplying sunscreen while outdoors and only a minority (37/121 = 30.58%) reported reapplying sunscreen after swimming or perspiring. Photoprotective practices are summarized in Table 2.

Table 2 Sun protection practices in patients with malignant melanoma, those with atypical mole syndrome, and controls

PMH: Past medical history; MM: Malignant melanoma; AMS: Atypical mole syndrome; UV: Ultraviolet.

Forty-six (46/121 = 38%) patients reported daily use of UV sunglasses. There was a tendency of more frequent daily use of sunglasses in the MM and AMS groups in contrast to the control group, but this was not statistically significant (P= 0.303). Eleven (9.1%) and four (3.3%) patients reported daily use of broad-brimmed hats and long-sleeved shirts, respectively, with no significant difference among the three groups. Only a minority of patients (22/121 = 18.2%) avoided the sun daily during peak hours of sunlight intensity.

Photoprotection education and perceived barriers

Most of the patients, 90/121 (74.4%), had been given advice on how to protect their skin from sunlight, with 86/121 (71.1%) receiving that advice from their family doctor. Photoprotection education is summarized in Table 3.

One third of patients (45/121 = 37%) were given sun protection education from a health-care professional more than three times; half of them (63/121 = 52.1%) were educated from multimedia sources; and most of them (104/121 = 86%) were given written photoprotective advice.

Most of the patients (88/121 = 73%) were interested in receiving education. Eighty-eight patients (72.7%) were interested in receiving sun protection advice from a health-care worker and 74 (61.2%) were interested in receiving photoprotection advice from multimedia sources.

Half of the patients (63/121 = 52.1%) had encountered barriers that discouraged them from practicing sun protection. These barriers are summarized in Table 4. A quarter of them (27/121 = 22.3%) claimed that they did not have time to practice photoprotection measures. Concerns over adequate vitamin D levels and financial concerns were reported by 28.9% and 15.7%, respectively. Only a minority reported appearance concerns (4.1%), difficulty in obtaining materials (5.8%), or previous unpleasant experiences with and bad reactions to sunscreen (7% and 0.8%, respectively). There was no statistical difference among the three groups in our study.

DlSCUSSlON

To the best of our knowledge, we have here presented the first study of its kind describing demographic and clinical characteristics and assessing awareness, knowledge, attitudes, and barriers toward photoprotective practices among patients with MM and AMS and a control group. We conducted our study in the city of Heraklion, Crete, Greece, which has a very high UV index and a significantly homogeneous population. Limitations of our study include the small sample of patients and the singlecenter location.

Our evidence indicates that adapting effective photoprotective practices, such as the daily use of high SPF sunblock, wearing a broad-brimmed hat and a long-sleeved shirt, and avoiding sun exposure between the peak hours of 10:00 a.m. to 4:00 p.m. protect against the development of skin cancer[8-12]. Therefore, assessing photoprotective education and attitudes and providing sun protection education are both important and effective in preventing skin cancer, especially in areas with high UV indexes such as Crete, Greece.

Table 3 Sun protection education in patients with malignant melanoma, those with atypical mole syndrome, and controls

Our survey highlighted that although most of the patients used sunscreen (104/121 = 86%), and half of them (57/121 = 47.1%) used sunscreen with an SPF of ＞ 50, only a small proportion of them (22/121 = 18.2%) applied it daily, and the majority (84/121 = 69.4%) applied it only during the summer. Many participants reported never having worn a broad-brimmed hat (38/121 = 31.4%), a long-sleeved shirt, or long pants (29/121 = 24%) to protect themselves from sunlight. There was no statistical difference among the three groups regarding sun protection practices.

Most of the patients (90/121 = 74.4%) recalled having received advice on how to protect their skin from sunlight. This shows high recall of receiving photoprotective education (this number has varied from 27.5% to 96% in previous papers). Our survey highlights that, despite recalling having received adequate photoprotection education, the implementation of sun protective practices in all the three groups remained suboptimal. Our study showed that adherence to photoprotective practices did not correlate with education level. Previous studies have documented that a lack of post-secondary education was correlated with a reduced adoption of sun protective behaviors[13-18].

Table 4 Perceived barriers to implementation of photoprotection practices in patients with malignant melanoma, those with atypical mole syndrome, and controls

Several barriers regarding photoprotection have been reported in the literature. In our cohort, the three most-cited barriers were “concerns over adequate vitamin D” (35/121 = 28.9%), “hassle/lack of time” (27/121 = 22.3%), and “cost/financial concerns” (19/121 = 15.7%). Only the barrier “lack of time” was consistent with previous studies[19-23].

We also found that 72.7% of the subjects expressed interest in receiving photoprotection advice from a health-care worker and 61.2% from multimedia sources. This indicates that patients might prefer receiving verbal advice from a health-care professional, and that electronic devices might also play a crucial role in relevant education[24-27]. However, the use of multimedia methods in educating people on photoprotective practices may be inefficient for older patients.

Our study has both strengths and limitations. A dermatologist assessed all participants, and the questionnaire was not only self-reported but also the patient and the dermatologist completed the questionnaire together at the same time. The dermatologist, who examined the patient, gave more accurate data. Furthermore, the design of our study involves consecutive patients who were recruited during a specific timeline. Limitations include the small sample of patients and the single-center hospital-based nature of the study. We recruited patients and controls consecutively from a tertiary referral mole clinic who were dermatology department patients. These patients might be more motivated toward skin cancer prevention knowledge and photoprotection measures, which may limit the generalizability of our results.

CONCLUSlON

Considerable efforts should be made to raise awareness regarding photoprotection practices with the aim to prevent skin cancer in patients with MM and AMS.

ARTlCLE HlGHLlGHTS

Research background

Patients with atypical mole syndrome (AMS) have a 3- to 20-fold higher risk of developing malignant melanoma (MM) than individuals without.

Research motivation

The most modifiable risk factor for developing MM is the ongoing ultraviolet exposure.

Research objectives

To assess awareness, knowledge, and attitudes towards sun protection among patients with MM and AMS.

Research methods

A written survey was administer ed to patients with MM, those with AMS, and a control group who attended a specialist mole clinic in Heraklion in Greece.

Research results

In total 121 subjects participated in the study. Their mean age was 43.92 ± 12.55 years. There were 66(54.4%) females and 55 (45.4%) males. Forty-seven (38.8%) patients had AMS, 26 (21.5%) had a past medical history (PMH) of MM, and 48 (39.7%) attended the clinic for a full skin checkup for their naevi without having AMS or MM. 104 (86%) participants reported using sunscreen. Approximately 74.4% of patients recalled having received advice on how to protect their skin from sunlight. The most mentioned barriers in photoprotection were concerns over adequate vitamin D and lack of time.

Research conclusions

Despite mentioning having received ad equate education in photoprotection, adherence to photoprotection practices is suboptimal in patients with MM and AMS.

Research perspectives

Larger prospective studies could be performed comparing awareness, knowledge, and attitudes towards photoprotection among patients with MM and AMS before and after receiving education in photoprotection.

FOOTNOTES

Author contributions:Koumaki D, Papadakis M, and Krasagakis K contributed to designing the study; Koumaki D contributed to collecting and analyzing the data, and writing the paper; Papadakis M contributed to analyzing the data; Kouloumvakou S contributed to collecting the data; Koumaki D, Papadakis M, and Krasagakis K contributed to revising and approving the paper.

lnstitutional review board statement:The study was approved by the institutional review board of the University Hospital of Heraklion, Greece.

lnformed consent statement:All patients gave informed consent.

Conflict-of-interest statement:All authors declare no conflict of interest for this article.

Data sharing statement:The datasets used for analysis are available from the corresponding author upon reasonable request.

Open-Access:This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

Country/Territory of origin:Greece

ORClD number:Marios Papadakis 0000-0002-9020-874X.

S-Editor:Wang LL

L-Editor:Wang TQ

P-Editor:Wang LL