Howard K. Koh

Use of health services before the diagnosis of melanoma: implications for early detection and screening.

Objective:To determine whether persons with melanoma were integrated into the health care system prior to diagnosis.Design:Population-based survey by mailed questionnaire.Patients/participants:216 persons with malignant melanoma diagnosed in Massachusetts in 1986.Main results:Of the 216 cases, 87% stated that they had regular physicians, 63% had seen those physicians in the year prior to diagnosis, but only 20% had regular dermatologists. Overall, only 24% had examined their own skin prior to diagnosis and 20% reported physician skin examinations.Conclusions:Persons diagnosed with melanoma reported extensive contact with regular physicians in the year prior to diagnosis. However, most of these persons neither received skin examinations nor examined their own skin during that time. While additional study is necessary to confirm these findings, the authors suggest that physicians caring for patients at risk for melanoma integrate melanoma screening into routine care.

Sunbathing habits and sunscreen use among white adults: results of a national survey.

OBJECTIVESnThis study assessed current levels of sunbathing and sunscreen use in the United States.nnnMETHODSnFrom a general-population telephone survey of aquatic activities among adults in 3042 US households, we examined responses by the 2459 Whites.nnnRESULTSnMost adults (59%) reported sunbathing during the past year, and 25% reported frequent sunbathing. Of the subsample who reported sunbathing during the month before the interview, 47% routinely used sunscreen. Of these individuals, almost half did not use sunscreens with a solar protection factor of 15 or higher.nnnCONCLUSIONSnAbout a quarter of US White adults report frequent sunbathing, and only about a quarter of sunbathers use sunscreens at recommended levels. These results should help focus future sun protection educational efforts.

Factors associated with smoking among children and adolescents in Connecticut

INTRODUCTIONnThe age of smoking initiation has dropped over the past four decades. Since behaviors and attitudes adopted in late childhood or early adolescence predict future smoking, it is important to understand the smoking and other risk-taking behaviors and attitudes of children aged 12 and younger. The goal of the analyses presented here was to describe behavioral and attitudinal factors associated with smoking among elementary school (grades 4-6), middle school (grade 7-8), and high school (grades 9-12) students in Connecticut.nnnMETHODSnWe have used data from 8 years (1988-1996) of an anonymous, self-administered health risk appraisal survey given to children and adolescents in self-selected public and private schools. We compared the proportion of smokers and nonsmokers who reported various behaviors and attitudes and compared them with the chi-square test.nnnRESULTSnFifteen percent (n = 4,884) of the total population (n = 31, 861) were current smokers. At all grade levels, current smokers were more likely than nonsmokers to engage in risk-taking behaviors, and to report more stress and depression. Indicators of risk-taking and stress were also associated with the intent to smoke among children in grades 4-6.nnnCONCLUSIONSnSmoking occurs within the context of other risk-taking behavior and psychological distress, among both children and older adolescents. Our data provide support for the idea of early identification and targeting of children at high risk of smoking in elementary school, possibly as early as grade four.

Cutaneous melanoma mortality among the socioeconomically disadvantaged in Massachusetts.

OBJECTIVESnTo identify groups for melanoma prevention and early detection programs, this study explored the hypothesis that survival with cutaneous melanoma is disproportionately lower for persons of lower socioeconomic status.nnnMETHODSnMassachusetts Cancer Registry and Registry of Vital Records and Statistics data (1982 through 1987) on 3288 incident cases and 1023 deaths from cutaneous melanoma were analyzed. Mortality/incidence ratios were calculated and compared, predictors of late stage disease were examined with logistic regression analysis, and a proportional hazards regression analysis that used death registration as the outcome measure for incident cases was performed.nnnRESULTSnLower socioeconomic status was associated with a higher mortality/incidence ratio after adjustment for age and sex. For education, the mortality/incidence ratio was 0.37 in the lower group vs 0.25 in the higher group (rate ratio = 1.48, 95% confidence interval [CI] = 1.08, 2.03). Late stage disease was independently associated with lower income (rate ratio for lowest vs highest tertile = 1.64, 95% CI = 1.20, 2.25), and melanoma mortality among case patients was associated with lower education (rate ratio = 1.52, 95% CI = 1.09, 213).nnnCONCLUSIONSnMelanoma patients of lower socioeconomic status may be more likely to die from their melanoma than patients of higher socioeconomic status. Low- SES communities may be appropriate intervention targets.

The Falmouth Safe Skin Project: Evaluation of a Community Program to Promote Sun Protection in Youth

Amultidimensional community-based skin cancer prevention programwas conducted in Falmouth, Massachusetts, combining community activism with publicity campaigns and behavioral interventions to improve sun protection knowledge; attitudes; and practices in parents, caregivers, and children. The programwas associated with improvements in target outcomes, based on two telephone surveys of random samples of parents (n= 401, 404). After program implementation, fewer parents reported sunburning of their children, particularly among children 6 years old or younger (18.6% in 1994 vs. 3.2% in 1997), and more parents reported children using sunscreen, particularly continuous use at the beach (from 47.4% to 69.9% in younger children). Hat and shirt use did not increase. Improvements also were seen in parent role modeling of sun protection practices, parents’self-efficacy in protecting children from the sun, and sun protection knowledge. While these findings must be interpreted cautiously, they do suggest that this project was effective in promoting sun protection.

Public knowledge, awareness, and perceptions of the association between skin aging and smoking

BACKGROUNDnAlthough the tobacco industry promotes images of glamour, 2 decades of epidemiologic research have concluded the opposite: smokers have enhanced facial aging and skin wrinkling compared with nonsmokers.nnnOBJECTIVEnThe purpose of this study was to obtain information on the publics awareness of the association between cigarette smoking and skin aging.nnnMETHODSnIn the spring of 1994, the Maine-wide Cooperative Telephone Survey conducted telephone interviews in 678 randomly selected, nonseasonal dwelling units in Maine. From each dwelling unit, one randomly selected adult resident was interviewed to assess awareness of the association of skin aging with smoking.nnnRESULTSnFifty-eight percent of those persons interviewed had smoked at least 100 cigarettes, and among them, 24% were current smokers (28% men, 21% women). After adjusting for sex, age, and education, current smokers remained less likely to be aware of this association compared with former (prevalence ratio, 0.78; 95% confidence interval, 0.64-0.95) and never smokers (prevalence ratio, 0.87; 95% confidence interval, 0.70-1.07). However, nearly one fourth of smokers in this study believed that most or some smokers would consider this information in their decision to quit, with slightly higher findings in young smokers.nnnCONCLUSIONnThese findings are of public health importance. While strategies for framing messages about the association between smoking and facial aging await further study, this association deserves to be considered in all tobacco control and counter-advertising campaigns.

Adjuvant therapy for cutaneous malignant melanoma

We discuss the current status of adjuvant therapy for melanoma by first reviewing the rationale and goals of adjuvant therapy and then analyzing the results of published randomized trials. We pay particular attention to adjuvant interferon trials that raise many challenging issues in the management of patients with melanoma at high risk of recurrence. Past adjuvant trials have used immunotherapeutic approaches, chemotherapy, radiation therapy, as well as hormonal and retinoid therapy. We also summarize ongoing adjuvant trials.

Participant satisfaction and value in American Academy of Dermatology and American Cancer Society skin cancer screening programs in Massachusetts

BACKGROUNDnMore than 1 million Americans have attended the American Academy of Dermatologys Melanoma/Skin Cancer Screening Programs since 1985. However, there have been no reports of the participants perceived value, satisfaction, and benefits of skin cancer screening.nnnOBJECTIVEnWe attempted to measure the benefits and subsequent screening practices of persons with presumptive positive screening diagnoses.nnnMETHODSnA self-administered questionnaire was sent to participants with positive screening diagnoses in Massachusetts.nnnRESULTSnOf the 643 respondents, 81% rated their satisfaction as high and 84% had similar ratings for the value of the screening. Screenings apparently led to an increase in self-screening (60% before screening compared with 84% after screening).nnnCONCLUSIONnAlthough screening appears to have relatively strong benefits, further studies should be conducted nationally.