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Skin Cancer Knowledge and Prevention Practices Among Young Adult Athletes

Orsimarsi, Gianna

Journal of the Dermatology Nurses' Association: May/June 2019 - Volume 11 - Issue 3 - p 113–128
doi: 10.1097/JDN.0000000000000468
FEATURE ARTICLES
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ABSTRACT The Skin Cancer Foundation defines skin cancer as uncontrolled growth of abnormal skin cells (The Skin Cancer Foundation, 2016b). Skin cancer risk factors include ultraviolet radiation and sun exposure (American Cancer Society, 2016b). Young adult outdoor athletes are frequently exposed to the sun and are at an increased risk of developing skin cancer. Research found young adult athletes average 1,000 hours in the sun annually for their sport (Wysong et al., 2012). This article examines current literature and studies that have researched young adult athletes on their knowledge of being at an increased skin cancer risk as well as their attitudes and sun protective behaviors in regard to skin cancer and prevention. The purpose is to evaluate as a whole whether frequent sun exposure influences young adult athletes’ use of preventative measures such as sunscreen or protective clothing. Results found that most athletes were knowledgeable of sunscreen use being a preventative measure for sun protection and skin cancer; however, sunscreen was not always applied (Lawler et al., 2012; Walker et al., 2014; Wysong et al., 2012). Results indicate that skin cancer and preventative practices among young adult athletes continue to be a concern, and therefore research should focus on addressing ways to promote skin cancer prevention practices as well as screening, management, and treatment strategies (U.S. Department of Health and Human Services, 2014).

Gianna Orsimarsi, MSN, APN, Thomas Jefferson University, Philadelphia, PA.

The author declares no conflict of interest.

Correspondence concerning this article should be addressed to Gianna Orsimarsi, MSN, APN.

Skin cancer is defined by The Skin Cancer Foundation as uncontrolled growth of abnormal skin cells (The Skin Cancer Foundation, 2016b). According to the American Cancer Society (2016b), in the United States, skin cancer is the most commonly diagnosed cancer. Risk factors include frequent sun exposure and poor use of preventative measures, including sunscreen and protective clothing (American Cancer Society, 2016b). Young adult outdoor athletes are frequently exposed to the sun as a result of practicing and participating in outdoor sporting events and therefore are at a greater risk of developing skin cancer (Dubas & Adams, 2012).

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Problem Statement

Taking precautionary measures and limiting skin exposure to the sun and UV radiation reduce the risk of developing skin cancer greatly. Preventative measures include limiting sun exposure and not using indoor tanning devices as well as wearing protective clothing and broad-spectrum sunscreen with a sun protection factor (SPF) of 30 or higher (American Cancer Society, 2016b). Young adult athletes participating in outdoor sports are at an increased risk for developing skin cancer as a result of frequent sun exposure during practices, games, and tournaments (Dubas & Adams, 2012). A recent study conducted at Duke and Stanford Universities found that the average National Collegiate Athletic Association (NCAA) athlete spent 4 hours per day and 10 months per year outdoors training for his or her sports, which equated to about 1,000 hours of time spent in the sun annually (Wysong et al., 2012). Young adult athletes, given their frequent sun exposure, need to adopt preventative measures now to decrease their risk of getting skin cancer in the future. It is important to determine: Does young adult athletes’ frequent sun exposure influence their use of preventative measures, such as sunscreen or protective clothing use, in an effort to protect themselves from skin cancer?

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BACKGROUND AND SIGNIFICANCE

Several forms of skin cancer exist including basal cell carcinoma, squamous cell carcinoma, and melanoma (American Cancer Society, 2016b). Skin cancer can develop when the skin is exposed to excessive amounts of ultraviolet (UV) radiation. Through excessive UV radiation, unrepaired DNA damage to skin cells occurs, which then leads to mutations or defects in the skin cells. These cells can then grow uncontrollably, forming malignant tumors of the skin (The Skin Cancer Foundation, 2016b).

The skin consists of two layers: the epidermis and the dermis. The epidermis, being the top layer, is made up of three types of cells: squamous cells, basal cells, and melanocytes. The top layer of the epidermis consists of squamous cells, and then underneath are the basal cells and melanocytes that make up the lower layer of the epidermis. Melanocytes produce melanin, which creates pigment and darkens the skin (National Cancer Institute, 2016). Skin cancer can develop from the three main types of cells in the epidermis layer of the skin. With basal cell carcinoma, the cancer cells develop on sun-exposed areas and tend to grow slow or invade other parts of the body. Squamous cell cancers also develop on sun-exposed areas of the body but tend to grow into deeper layers of the skin and spread to other parts of the body. This is unlike basal cell cancers. However, spreading to other parts is still rare with squamous cell carcinoma. The pigment-making cells of the skin, melanocytes, can develop into melanoma (American Cancer Society, 2016a). Although melanoma is a rare form of skin cancer, it is the most likely form of skin cancer to invade nearby tissues and spread to other parts of the body (National Cancer Institute, 2016).

In the United States, over 4 million cases of basal cell carcinoma are diagnosed yearly, making it the most common form of skin cancer. More than 1 million cases of squamous cell carcinoma are diagnosed in U.S. citizens each year, making it the second most common form of skin cancer (The Skin Cancer Foundation, 2016b). The third most common type of skin cancer, melanoma, is the most dangerous and accounts for most skin cancer deaths. According to the American Cancer Society (2016b), over the past 5 years, incidence rates for cutaneous melanoma are declining or plateauing for individuals 49 years old or younger. In contrast, the incidence rate for cutaneous melanoma for individuals 50 years old or older in the United States has seen a 2.6% increase per year since 1996. However, if we examine a younger age group within the former time frame, we find different results: Between the years 2008 and 2012, incidence rates have declined in men and women aged 20–29 years by about 3% (American Cancer Society, 2016b).

The American Cancer Society estimates new cases for melanoma in the United States in both genders to reach 76,380 for the year 2016. The estimated number of U.S. citizens to die from melanoma for the year 2016 is 10,130, in addition to 3,520 deaths for other types of skin cancer (American Cancer Society, 2016b). The survival rate for melanoma, if detected early, is about 98%. However, if the cancer reaches the lymph nodes, the survival rate drops to about 63%. If the cancer spreads to other organs, that survival rate drops to 17% (The Skin Cancer Foundation, 2016a). The statistics above are concerning, especially to those with many risk factors.

Several risk factors exist for developing skin cancer, with some more severe than others. One of the greatest risk factors for developing skin cancer is excessive UV radiation, whether it be from sunlight or indoor tanning devices. According to the American Cancer Society (2016b), other risk factors include sun sensitivity, having natural blonde or red hair, sun burning easily or difficulty tanning, excessive sun exposure previously, history of sunburns, immunosuppression diseases or treatments, and a previous skin cancer history. Those with a personal or family history of melanoma or having large, atypical moles or more than 50 moles are at a greater risk for developing melanoma (American Cancer Society, 2016b). Exposure to the chemical arsenic as well as smoking tobacco has been linked to skin cancer and can contribute to risk as well (American Cancer Society, 2016a).

All areas of skin on an individual’s body should be examined regularly for new or changing growths and reported to a healthcare provider if changes occur; in that way, prompt treatment can be done. For melanoma, the ABCDE rule exists (refer to Appendix B, Figure 1). The five ABCDE characteristics are warning signs for the most common type of skin cancer, melanoma (American Cancer Society, 2016b). The estimated annual cost for treating skin cancers in the United States alone is 8.1 billion dollars (The Skin Cancer Foundation, 2016b). With the high cost of treatment, incidence rates, and mortality rates, a focus on education and preventative measures is necessary.

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Theoretical Framework

The health promotion model designed by Nola Pender has been used in nursing since 1982. In the article, “Nola Pender-Nursing Theorist” (Nursing Theory, 2016b), it is stated that the health promotion model was created in an effort to show that individual health behaviors are impacted and shaped by their personal characteristics as well as their different life experiences. This model focuses on positive motivation and preventing health problems before they develop, unlike many previous models that focused on treatment and management of health problems (Nursing Theory, 2016b). Stated in the Nursing Theory (2016a), the health promotion model is made up of three areas: individual characteristics and experiences, behavior-specific cognitions and affect, and behavioral outcomes. The assumptions of the health promotion model are that individuals actively seek to regulate their own behaviors as well as have their behaviors influenced over time as a result of interacting with the environment and others such as with family, friends, and health professionals. The model also contains 13 theoretical statements that provide a basis for health behavior investigative work. The model suggests that prior behaviors and inherited characteristics influence behaviors related to health promotion. It also suggests that individuals engage in certain behaviors because of an anticipated benefit. Families, peers, and healthcare professionals as well as situations in the outside environment can also influence health promoting behaviors either positively or negatively. Perceived barriers as well as individual self-efficacy can influence commitment to action and follow-through with certain behaviors. Having positive affect or emotions with certain behaviors also influences the commitment to action and is more likely to lead to an increase in the certain behaviors. Finally, the model suggests that commitment to a specific plan of action influences how likely the health promoting behaviors are to be maintained over time and that individuals have the ability to modify cognitions, their environments, and affect to create health behavior incentives (Nursing Theory, 2016a). Several studies that examined college athlete behaviors related to skin cancer and prevention had results that supported the assumptions and theoretical statements of the health promotion model. For example, a study conducted by Wysong et al. (2012) found that sunscreen use was influenced by the frequency in which coaches and athletic administrators discussed sunscreen use and sun exposure with the young adult athlete study participants. In the study, sunscreen use significantly increased with the amount of time coaches and athletic administrators spent discussing sunscreen use and sun exposure (Wysong et al., 2012).

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Search Strategy

Between the dates of September 25, 2016, and February 1, 2017, PubMed and ScienceDirect databases were searched using search terms, alone or in combination: “skin cancer,” “melanoma,” “prevention,” “young adults,” “athletes,” “behaviors,” “attitudes,” and “knowledge.” The search was limited to studies published within the last 5 years that had also been peer reviewed. The initial search found about 300 articles. Articles were then further excluded for several reasons including studies that researched athletes who did not play an outdoor sport as well as studies that did not have most athletes from a young adult population, considered within the ages 18–45 years. The eight most relevant studies were selected for inclusion in the literature review (refer to Appendix A). The included studies consisted of one quasi-experimental one-group pretest/posttest design, one quantitative randomized controlled trial (RCT), and six cross-sectional survey and questionnaire designs (Bagatti, Englert, & Cline, 2015; Buller et al., 2012; Dubas & Adams, 2012; Ellis, Mohr, Indika, & Salkey, 2012; Hobbs, Nahar, Ford, Bass, & Brodell, 2014; Lawler et al., 2012; Walker et al., 2014; Wysong et al., 2012).

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Review of Literature

Bagatti et al. (2015) conducted a quasi-experimental one-group pretest/posttest design during the fall semester of 2014 at a small private liberal arts university in Western Pennsylvania. The aim of the study was to evaluate the knowledge, behaviors, and attitudes of 72 female college athletes in regard to skin cancer. To be included in the study, one had to be involved on a collegiate athletic team, at least 18 years old, able to speak English, and able to complete the pretest and posttest in one sitting. Participants were given a valid 28-question melanoma pretest that assessed risk, knowledge, and sun protective behaviors. The pretest included questions related to assessment of personal risk, concern level, protective behaviors, and melanoma knowledge as well as four images of normal and abnormal nevi from The Skin Cancer Foundation. After the pretest was given, an educational intervention was conducted at the practice facilities. An oral presentation and handout were given containing facts and statistics, risk factors, harmful effects of UV radiation, preventative measures, and self-examination techniques of the skin, including the ABCDE characteristics of melanoma. After the oral presentation, the posttest was given, containing four original pretest questions along with 12 different questions assessing knowledge, behavior, and attitude as well as four different nevi images from The Skin Cancer Foundation. After the posttest, participants were given sunscreen with SPF 30 samples, Melanoma Research Foundation brochures, and The Skin Cancer Foundation’s skin self-examination card and brochure. Participants ranged in age from 18 to 22 years, with a mean age of 19.74 years. Most of the participants were White, accounting for 90.3%; 2.8% were Black; 2.8% were Latino; 1.4% were Asian; and 1.4% were Pacific Islanders. Most female athlete participants either played lacrosse or soccer or were on the rowing team. Results found that, on average, the amount of time spent in the sun per week was 15.03 hours. In terms of tanning device use, more than half of the participants reported using a tanning device in the past. However, only 2.8% reporting weekly or more use of tanning devices, and 27.8% reported using tanning devices very infrequently. As for sunburns, 80.6% reported having been sunburnt three or more times during their life, and 86.1% reported that they try to get tan while at home and on vacation. Only 23.6% of the participants reported use of sunscreen, with more than 75% reporting that they do not use sunscreen at all. After the educational intervention, there was a statistically significant improvement in the intent to begin using sunscreen habitually when outdoors, with 79.2% of the participants reporting that they would start using sunscreen consistently when outside. There was also a statistically significant improvement with intent to self-examine skin for moles after the educational intervention. Before the educational intervention, 51.4% of the participants reported that they never check their skin for moles, but after the intervention, 94.4% of the participants reported they would start examining their skin for moles regularly. With the educational intervention, the participants’ ability to identify normal and abnormal nevi improved, with mean correct answers being 3.16 at pretest and 3.73 at posttest. A paired t test was conducted to compare the likelihood of participants to visit their healthcare providers within 6 months before and after the educational intervention. Participants were significantly more likely to go see their healthcare providers for their skin postintervention, t(70) = 9.365, p < .001. The results of this study support the idea that frequent sun exposure during outdoor athletic activity in young adults does not increase use of preventative measures, such as sunscreen, against skin cancer. However, results of this study do suggest that educating young adult athletes on skin cancer improves their behaviors, attitudes, and knowledge in regard to skin cancer prevention and protection from the UV radiation (Bagatti et al., 2015).

A 4-week randomized controlled trial was conducted by Dubas and Adams (2012) to determine the effect of sunscreen availability on its application among outdoor NCAA Division I female golfers. There were 10 golf teams from colleges in Ohio, Kentucky, Indiana, and Illinois that participated, with 83 participants, in which 39 participants were assigned to the control group and 44 participants were assigned to the treatment group. At the beginning of the study, all participants completed the same self-administered six-question survey with questions related to skin type, sunscreen use, age, and year in school. However, treatment groups were given five tubes of SPF 30+ sunscreen lotion after survey completion, and each treatment team had to keep a 1-gallon tub of SPF 30+ sunscreen at their locker room entrances for the duration of the 4-week study period. The treatment participants were not directed to apply the sunscreen and just told to keep at least one tube of the sunscreen in their golf bags at all times. Upon completion of the 4 weeks, results were calculated and showed that having sunscreen available to athletes resulted in 1.13 days per week of increase in sunscreen use (p = .008). Before the intervention, there was no statistical difference in sunscreen use between the control and treatment groups. In terms of weather, there was no statistical difference between the two groups for weather temperature and cloud levels. Although the treatment group increased their reapplication by 20%, this was not statistically significant (p = .10). Reapplication of sunscreen with the control group did not change over the course of the study. Although the athletes of the study were exposed to the sun while outdoors for practice and competition, results did not indicate a significant increase in sunscreen use as a preventative measure against skin cancer. Reasons why the treatment and control groups did not use sunscreen included preference for tan skin, inability to sunburn, inconvenience, and inaccessibility (Dubas & Adams, 2012).

A cross-sectional study was conducted at the Southern University in the United States to assess college athletesknowledge, attitudes, and behaviors in regard to skin cancer and whether or not knowledge and attitudes correlated with behaviors for skin cancer prevention. The study was conducted by Hobbs et al. (2014). The sample consisted of 343 Division I athletes aged 18–24 years, with 54.8% men and 45.2% women. The majority, 58.6% of the participants, was White. African Americans made up 34.4% of the sample, 1.8% were Hispanic, 0.6% were Asian, and 4.6% were considered “other.” Participants were given a 55-question questionnaire that consisted of demographic questions as well as questions pertaining to protection from the sun and skin cancer risks. The questionnaire was a modified version of the Melanoma Risk Behavior Survey. Of the 55 questions, 24 questions were focused on knowledge related to melanoma. There were 13 questions that assessed sun and tanning behaviors. Another 11 questions on attitudes were rated on a 5-point Likert-type scale, with 1 = strongly disagree and 5 = strongly agree. For the knowledge section, the total highest score could have been 24. The mean score was 8.88 ± 4.39. These results showed that the college athlete participants lacked basic knowledge about skin cancer and protection from the sun. For example, 44.9% of the participants knew how to apply sunscreen 15–30 minutes before going outdoors, but only 35% knew how to reapply sunscreen every hour. In terms of risk factors, only 20.7% knew that a significant risk factor is spending times outdoors. The results from the attitude portion of the questionnaire showed that most participants, 83%, believed the statement “tanning beds improve one’s overall health.” Among the participants who reported a tan improves appearance (17.5%) and a positive look of health (27.4%), they also reported excessive sun exposure and sun bathing. A concerning finding is that only 42.6% strongly disagreed with the statement “a good tan is worth the increased risk of skin cancer.” There was a significance between race and knowledge, with darker pigmented races scoring lower overall on the knowledge portion of the questionnaire. Overall, there was a medium level of appropriate attitudes toward sun protection, with a mean score of 41.91 ± 6.22. For the behaviors analysis, results showed that the mean behavior score was 3.00 ± 2.70, meaning that the participants reported a low level of sun protection behaviors. There was no significance between age and skin protection behaviors. All races scored low for the behavior portion of the questionnaire, with Asians and African Americans having the lowest scores. There was a significant relationship between race and sun protection behaviors, χ2 = 67.78, p = .031. For sunscreen use, only 23% reported regular use of sunscreen 50% or more of the time during practices/games when exposed to the sun. Only 13.7% reported reapplying sunscreen every 3 hours more than 50% of the time when in the sun during practices and games. Only 20.7% reported seeing a doctor to have their skin examined. The participants also reported that most of them do not limit their time in the sun during the peak hours of 10 a.m. and 4 p.m. or wear protective clothing. The results also showed a significantly positive relationship between knowledge and behaviors, r = .244, p < .05, meaning that educating young adult athletes on risks and prevention of skin cancer may increase their sun protective behaviors, similar to findings in the study conducted by Bagatti et al. (2015). Results of this study are consistent with the previous studies reviewed in that frequent sun exposure does not positively influence young adult athletes’ use of preventative measures against sun exposure and skin cancer (Hobbs et al., 2014).

Two hundred thirty-seven young adult athletes from 24 Australian outdoor club sports teams participated in a cross-sectional questionnaire study by Lawler et al. (2012) where they completed a self-administered survey to examine the associations of sun protection habit strength and use of sunscreen during outdoor physical activity and sporting environments. The mean age of participants was 23.2 years. The survey contained six questions rated on a 6-point Likert scale that were related to frequency of protecting themselves from the sun while doing outdoor physical activities. The responses were summed up to create a self-report habit index score. High habit strength was considered a score of 24 or greater, and anything less than 24 was considered a low habit strength. Results of the study support similar study findings that sunscreen use and skin protection from the sun remain low among young adult athletes despite frequent sun exposure. Results found that only 20.2% of the participants reported adequate, frequent, or regular sunscreen use during their organized sports and 29.5% of the participants reported no sunscreen use. For generalized outdoor physical activity, more participants reported adequate use of sunscreen (48.9%). No or rare sunscreen use during general outdoor physical activity was reported by 26.6% of the participants. High sun protection habit strength was significantly associated with sunscreen use during organized sports and general outdoor physical activity. The participants with a high sun protection habit strength had an odds ratio of adequate sunscreen use, meaning frequent or regular use, that was 17 times the amount of those who had a low habit strength score. As for general outdoor physical activity, the odds ratio for adequate sunscreen use in those with high sun protection habit strength scores was 24 times that of low sun protection habit strength. Having a sunburn in the past was also associated with using sunscreen in both settings (Lawler et al., 2012).

An interview-type study conducted by Walker et al. (2014) during a summer in New Zealand found that about one third of participants, 33%, intentionally spend time in the sun to get a tan and as much as 66% of participants were concerned with getting skin cancer when exposing their skin to the sun. Of the 110 elite New Zealand outdoor athletes who participated in the study, 99 of them reported using sunscreen some of the time. The mean age of participants for the study was 23.53 years. Only 9% of the participants reported always using sunscreen before going out into the sun. In terms of reapplication of sunscreen, zero participants reported that they reapply sunscreen hourly and only five of 110 participants reported reapplication of sunscreen during training breaks. Furthermore, 44% of participants reported never reapplying sunscreen. A small percentage of participants, 8%, attributed their reapplication of sunscreen to feeling like they were burning so that was when they would reapply. There was no significance between the 45% of participants who reported being concerned with skin cancer and using sunscreen always or most of the time, compared with the 35% of participants who were not concerned about skin cancer and still reported using sunscreen most or all of the time. Only one participant reported always wearing a hat, and 40 participants reported always wearing sunglasses for sun protection. Unlike findings from the studies reviewed previously, most athletes of this study reported sunscreen use some of the time. However, no association existed for those concerned or not concerned with skin cancer and application of sunscreen use. Barriers to sunscreen application reported included time, reported by 68% of participants, and lack of availability, accounting for 61% of participants (Walker et al., 2014).

During the months of April 2010 to June 2011, another cross-sectional survey study was conducted to evaluate high-risk skin cancer and photoaging college athletes’ attitudes, personal characteristics, and barriers with use of sunscreen by Wysong et al. (2012). Two hundred ninety NCAA athletes aged greater than 18 years, from Duke and Stanford Universities, completed the 20-question survey. Results of the surveys found that more than 85% of participants spent more than 2 hours per day outdoors practicing and 88% of participants spent 7 months or more per year outdoors playing their sport. Sunburn was experienced by 84% of participants within the past year, and 28% reported having four or more sunburns. A high percentage of participants, 96%, reported that they agree sunscreen protects from developing skin cancer; however, only 70% of participants reported sunscreen use 3 days or fewer per week. Forty percent of participants reported never using sunscreen. Several barriers were mentioned by the NCAA athletes for not applying sunscreen while playing their sport (refer to Appendix B, Figure 2). Of the reasons for not using sunscreen, the most common answer was forgetting to apply the sunscreen. Other reasons included wanting to be tan, inconvenience, time consuming, acne causing, eye burning, and the belief that they would not sunburn without the sunscreen on. A large percentage of participants, 73%, also reported that their coaches and athletic administrators rarely discussed the importance of using sunscreen or sun exposure. Sunscreen use increased significantly with the frequency the coaches and athletic administrators discussed sunscreen use and exposure, which supports the concept that education can positively influence skin protective behaviors, including sunscreen use, to prevent skin cancer (Wysong et al., 2012).

Ellis et al. (2012) conducted a study using an anonymous, voluntary, Internet-based survey with multiple-choice-type questions to evaluate frequency and formulation of sunscreen use as well as parental and coach encouragement for sun protection. Once consent was given by coaches of U.S. collegiate athletic teams, the survey link was sent to coaches. Two hundred seventy-four athletes completed the survey, with most respondents living in the southern United States. Results found that sunscreen was more frequently used by women. However, most athletes, 60.95%, reported using sunscreen less than 25% of the time. Only 10.58% of athletes reported using sunscreen at least 75% of the time. Athletes who were encouraged by coaches and parents were more likely to use sunscreen. Barriers to sunscreen use reported in the study included slippery hands after use and difficulty finding sweat-proof sunscreen that did not cause eye irritation. The results of this study are consistent with the findings of similar studies that young adult athletes’ frequent sun exposure does not result in increased use of preventative measures such as sunscreen in an effort to protect themselves from skin cancer (Ellis et al., 2012).

Buller et al. (2012) conducted a cross-sectional survey study exploring the extent to which adult skiers and snowboarder athletes comply with sunscreen advice. The study surveyed athletes at 28 high-altitude ski areas in Western North America during the months of January to April. Athletes were interviewed by trained interviewers while riding chairlifts on the slopes. Most of the athletes, 67.9%, were young, non-Hispanic, college-educated men. Results found that 2,678 of 4,837 athletes reported sunscreen use that day. Of those who reported “yes” to wearing sunscreen, only 49.8% of athletes had sunscreen on with an SPF of 15 or greater. Most athletes, 73.2%, who reported sunscreen use, also reported applying the sunscreen 30 minutes before starting skiing or snowboarding. Of athletes reporting sunscreen use that day, only 20.4% of athletes reported reapplication of sunscreen 2 hours after original application. This study’s findings are consistent with the findings of the other reviewed studies that, although young adult athletes are frequently exposed to sun while doing their sports, most do not take the recommended precautionary measures, such as using sunscreen with an SPF of 15 or greater, to protect their skin from skin cancer (Buller et al., 2012).

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Summary Review of Literature

The eight studies explored young adult athletes from different parts of the world and evaluated their knowledge, attitudes, and behavioral practices for skin cancer and skin cancer prevention. Overall, most results found that young adult athletes do not report an increased use of sun protection methods, such as sunscreen or protective clothing, although they are frequently exposed to the sun (Bagatti et al., 2015; Buller et al., 2012; Dubas & Adams, 2012; Ellis et al., 2012; Hobbs et al., 2014; Lawler et al., 2012; Walker et al., 2014; Wysong et al., 2012). Two of the studies found that most young adult athletes spend, on average, a little over 2 hours per day in the sun (Bagatti et al., 2015; Wysong et al., 2012). Although several of the studies found that the young adult athletes were knowledgeable of sun exposure being a risk factor for cancer and that sunscreen can be used for prevention, most athletes did not always or frequently wear sunscreen while playing their sports and those who did so did not always reapply (Buller et al., 2012; Lawler et al., 2012; Walker et al., 2014; Wysong et al., 2012). One study found that the participants were not knowledgeable of sunscreen application and that having knowledge of sun protection correlated with increased sun protective behaviors (Hobbs et al., 2014). The four studies that explored barriers to sunscreen use all reported similar results. Barriers included inconvenience, time consumption, and limited availability (Dubas & Adams, 2012; Ellis et al., 2012; Hobbs et al., 2014; Wysong et al., 2012). Five of the six studies reported that a percentage of young adult athletes wanted to obtain a tan or thought that a tan made them look better or healthier (Bagatti et al., 2015; Dubas & Adams, 2012; Hobbs et al., 2014; Walker et al., 2014; Wysong et al., 2012). Some participants from two of the studies also reported believing they would not burn in the sun as reason for not using sunscreen (Dubas & Adams, 2012; Wysong et al., 2012). Meanwhile, one study found that 84% of participants had been sunburnt within the past year, and another study reported that 80.6% of participants had been sunburnt more than three times over the course of their lives (Bagatti et al., 2015; Wysong et al., 2012). A large majority rarely wore protective clothing while out in the sun as reported in two of the studies (Hobbs et al., 2014; Walker et al., 2014). In terms of examining skin for abnormal skin lesions, Bagatti et al. (2015) reported that 51.4% never check their skin, and Dubas and Adams (2012) found that only 20.7% of participants had their skin checked by professionals. In summary, all eight studies reviewed had similar findings in that frequent sun exposure among young adult athletes does not correlate to increased use of protective measures, such as sunscreen or protective clothing, to protect against skin cancer (Bagatti et al., 2015; Buller et al., 2012; Dubas & Adams, 2012; Ellis et al., 2012; Hobbs et al., 2014; Lawler et al., 2012; Walker et al., 2014; Wysong et al., 2012). However, with education, motivation for skin protection and use of sunscreen increased as reported by the studies done by Bagatti et al. and Wysong et al. (2012).

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CONCLUSION

Young adult athletes participating in outdoor sports are at an increased risk for developing skin cancer because of excessive exposure to UV radiation while practicing and competing (Bagatti et al., 2015; Wysong et al., 2012). However, many athletes do not frequently use sunscreen or protective clothing to guard their skin from the damaging UV rays. As evidenced by the findings from the eight studies reviewed, results revealed that frequent sun exposure does not impact most of young adult athletes’ use of preventative measures, such as sunscreen or protective clothing, in an effort to protect themselves from skin cancer (Bagatti et al., 2015; Buller et al., 2012; Dubas & Adams, 2012; Ellis et al., 2012; Hobbs et al., 2014; Lawler et al., 2012; Walker et al., 2014; Wysong et al., 2012). Because of the lack of engagement in preventative behaviors by young adult athletes against the sun, one call to action mentioned in “The Surgeon General’s Call to Action to Prevent Skin Cancer” by U.S. Department of Health and Human Services (HHS, 2014) is to have colleges, schools, and universities support sun protection in outdoor athletic settings, specifically for young adult athletes, in an attempt to increase sun protective behaviors and therefore lower skin cancer risk (HHS, 2014). As a result of the seriousness of skin cancer and its economic burden, costing the United States an estimated 8.1 billion dollars per year in treatment alone, more regulations and policies have been put into place (HHS, 2014). However, compliance with sunscreen use and protective measures against the sun is still lacking. Many organizations, such as the American Cancer Society, Centers for Disease Control and Prevention, and HHS, are continuing their efforts to research and educate the public on a national and global level in an attempt to prevent and treat against the different types of skin cancer (American Cancer Society, 2017; Centers for Disease Control and Prevention, 2014; HHS, 2014).

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                APPENDIX A

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                Appendix B

                Figure 1

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                Keywords:

                Skin Cancer; Prevention; Young Adults; Athletes; Behaviors; Knowledge

                Copyright © 2019 by the Dermatology Nurses' Association.