EDIFICE Melanoma survey: knowledge and attitudes on melanoma prevention and diagnosis

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1 DOI: /jdv JEADV ORIGINAL ARTICLE EDIFICE Melanoma survey: knowledge and attitudes on melanoma prevention and diagnosis P. Saiag, 1, * B. Sassolas, 2 L. Mortier, 3 F. Grange, 4 C. Robert, 5 C. Lhomel 6, C. Lebbe 7 1 Department of Dermatology, H^opital Ambroise Pare, Boulogne-Billancourt, France 2 Department of Internal Medicine and Respiratory Diseases, H^opital Cavale Blanche, Brest, France 3 Department of Dermatology, H^opital Claude Huriez, Lille, France 4 Department of Dermatology, Robert Debre University Hospital, Reims, France 5 Department of Dermatology, Institut Gustave Roussy, Villejuif, France 6 Roche, Boulogne-Billancourt, France 7 Department of Dermatology, H^opital Saint-Louis, Paris Diderot University, Inserm U976, Paris, France *Correspondence: P. Saiag. philippe.saiag@apr.aphp.fr Abstract Background Melanoma incidence is increasing worldwide thus justifying information campaigns aimed at reducing ultraviolet exposure levels and promoting early diagnosis. Objectives We set out to assess awareness, knowledge and attitudes of the French population with regard to melanoma prevention and early diagnosis, following more than 15 years of nationwide information campaigns. Methods The French nationwide observational survey, EDIFICE Melanoma, was conducted after the summer (September to October 2011) through structured telephone interviews of a representative sample of 1502 individuals aged 18 years, using the quota method. All French regions were represented. Results Respondents had heard of sun-induced skin damage: 92% knew that sun increases melanoma risk. Knowledge of sun-protection measures was also good: 97% correctly cited at least one method of photoprotection (clothing 80%, sunscreens 69%) and 97% declared that sun exposure should be reduced between 12 pm and 4 pm in France. Knowledge of melanoma was encouraging: 70% of respondents could define the disease accurately and 60% knew the ABCDE rule for early diagnosis. However, self-tanning and sunbed use were considered by 25% and 1 of respondents, respectively, to provide protection from skin cancer. Although 4 of respondents (58% of high-risk respondents) declared they had consulted a doctor at least once for a suspect skin lesion, their actual behaviour was less encouraging: 30% declared never or almost never protecting their skin; 25% declared regularly checking their skin for atypical nevi; 12% declared checking the entire skin surface. Declared behaviour was better in fair-skin responders and those with a history of sunburn or skin cancer. Conclusions Awareness of melanoma, early-diagnosis procedures and preventive behaviour has improved in the general French population since However, despite the good level of information, numerous misconceptions persist. Improved information campaigns in the future may help reduce the ever-increasing incidence of melanoma in France. Received: 21 July 2014; Accepted: 22 October 2014 Conflict of interest None declared. Funding sources EDIFICE surveys are funded by Roche SA. Introduction The incidence of melanoma is increasing worldwide; in France, it has doubled in 20 years, 1 with 9780 new cases of melanoma and 1531 specific deaths reported in Among the risk factors for melanoma, exposure to sunlight and ultraviolet (UV) radiation are the most significant: approximately two-third of the cases of melanoma can be attributed to excessive exposure to the sun, and that proportion is even greater in individuals with fair skin. 2 Melanoma is a particularly aggressive malignant tumour once metastases have developed. It can however be cured if it is resected in the early stages of development. Early detection is therefore critical. These data clearly justify the devel-

2 12 Saiag et al. opment of information campaigns aimed at reducing UV-exposure and promoting early diagnosis. The objective of our study was therefore to assess the awareness, knowledge and attitudes of the general public with regard to melanoma prevention and early diagnosis, after more than 15 years of information campaigns in France. Methods The French nationwide quantitative observational survey, EDI- FICE Melanoma, was conducted by telephone, from September 28 to October , among a representative sample of individuals aged 18 years and living in France. Representativeness of the survey sample for gender, age, profession and double stratification by geographical area and community size, as compared with the general French population, was ensured by use of the method of quotas, 3 based on the statistics of the French employment survey conducted in 2009 and updated in 2011 by the French national institute for statistics and economic studies (Insee). Quantitative data were described by the means and standard deviations; categorical data were expressed as the numbers in each category and corresponding percentages. All comparisons between two populations were carried out using Student s t-test for quantitative data, and the Z-test and the Chi-squared test for comparison of percentages and numbers, respectively, in the case of categorical data. 4 Results Of the initial persons with a telephone number, 1502 (aged 18 years) completed the questionnaire. Within that population, 1172 (78%) declared exposing themselves to the sun, 730 (48%) reported always or occasionally using sun-protection measures, and 442 (30%) declared using practically no protection. The population studied (N = 1502) comprised 715 (48%) men and 787 (52%) women, in the age ranges <40 years (552, 37%), years (536, 36%) and >60 years (414, 28%), with a mean age of 48.5 years [standard deviation (SD) 18.0]. Knowledge of melanoma and associated risk factors The sample population was questioned about melanoma risk factors, i.e., excessive exposure to the sun, history of exposure to artificial UV radiation, sunburn during childhood, personal or family history of melanoma, presence of atypical or numerous nevi, having fair skin, red or blond hair and light-coloured eyes. Among the 1502 respondents, 393 (26%) declared having at least one melanoma risk factor and 1109 (74%), no risk factors for melanoma; 172 (1) declared having a fair-skin phototype (I II) and 1330 (89%) a phototype III V. Among the possible factors increasing the risk for melanoma, excessive exposure to the sun was cited spontaneously by 76% of the respondents. Once the currently known risk factors for melanoma had been cited by the interviewer, almost all (99%) respondents agreed they had heard of them and knew that they are indeed factors that increase the melanoma risk (Fig. 1). Melanoma was defined by respondents as a skin cancer and/ or a mole degenerating into a malignant tumour. Approximately half of the respondents knew that melanoma can appear in any localization. Most of the respondents (70%) were able to accurately define the disease and 60% were aware of the ABCDE 2 rule for early diagnosis (Fig. 2). The known warning signs for melanoma were: modification of mole morphology (mentioned by 94% of respondents), colour (mentioned by 9 of respondents), enlargement (mentioned by 92% of respondents) and development of a skin tumour (mentioned by 82% of respondents). A mole with a different presentation to that of others was also considered as a warning sign by 76% of respondents. Attitude towards protection Knowledge on sun-protection measures was good: 97% of respondents correctly cited at least one approach to photopro- Too much sun exposure Atypical nevi Sunburn during childhood Use of sunbeds and UV lamps Personal history of melanoma Fair skin Family history of melanoma Numerous nevi 78% 74% 74% 70% 68% 66% 64% 9 Real risk factors 99% Trauma on nevi Personal history of cancer Tobacco Alcohol Deodorant Others Do not know 7 45% 38% 24% 22% Figure 1 Respondents knowledge of risk factors for melanoma.

3 Knowledge and attitudes on melanoma prevention and diagnosis 13 59% 55% 56% 42% 37% Figure 2 Potential signs of melanoma. Rate of answers to the question in your opinion, should the following criteria be associated with melanoma? 40% 39% 35% 38% 36% 1 17% 2% 2% 4% 2% 5% 2% 4% 5% changes shape changes color changes size looks like a red or is different from black spot the others A nevi that Do not know Probably not Certainly not Yes probably Yes certainly Protective clothes Use sunscreen Wear a hat Stay in shade Avoid midday sun % 72% Yes, absolutely I think so Not really No, not at all Do not know 2 37% subtotal yes 60% Wear sunglasses 22% Figure 3 Respondents knowledge of sun protection measures. 27% 1 tection: wearing protective clothing (72% of respondents), use of sunscreen (69% of respondents) and use of a hat or sunglasses (4 of respondents) (Fig. 3). A total of 97% of respondents declared that sun-exposure should be reduced at midday, between 12 pm and 4 pm. Although 59% of respondents declared that preparing the skin before sun-exposure is a good way to prevent skin cancer, another 25% and 1 of respondents believed that self-tanning (application of chemicals to obtain an artificial tan) and sunbeduse, respectively, provide protection from skin cancer. Information about effects of the sun and skin cancers To the question Do you consider yourself adequately informed about skin cancer?, only 2 answered yes, absolutely and 40% declared, not really or not at all (Fig. 4). The main source of information on skin cancers was the mass media (radio, TV, the Internet) for 77% of respondents; the press and healthcare professionals were mentioned by 42% and 4 of respondents, respectively. Approximately half of the respondents declared they had received advice regarding sun protection, mainly from a healthcare professional. Interestingly, the majority of responders declared they followed the advice to prevent skin cancers (Fig. 5). Figure 4 Information on skin cancer; answers to the question do you consider yourself adequately informed about skin cancer? In addition to its impact on the development of skin tumours, a majority of respondents also described other effects of the sun: has a beneficial impact on mood (96%), accelerates ageing of the skin (92%), promotes the development of allergies (76%) and decreases the skin s capacity to regenerate (64%). However, 14% declared that exposure to the sun exerts a protective effect against certain forms of cancer and 9%, a protective effect on the skin. A number of respondents also mentioned the positive effects of a suntan: for 90% of respondents, it makes people look good ; it is a reminder of good holidays (77%); it makes people feel happy and full of life (72%) and healthy (70%); and people with a tan look more beautiful (70%), more attractive (68%) and younger (29%). Melanoma screening In the event of a suspect skin lesion, 8 and 3 of respondents declared that they would consult a dermatologist or a

4 14 Saiag et al. Press 82% Follow advices from % Media 88% Healthcare professionals 90% Yes No Do not know family and close relations; word-of-mouth 92% Figure 5 Following advice to prevent skin cancers. Rate of answers to the question did you follow this advice? general practitioner, respectively, and 4 reported that they had already consulted a doctor at least once for a suspect skin lesion. Nevertheless, only 25% declared that they regularly check their skin for atypical nevi and 12%, that they check their entire skin surface. About 25% of respondents admitted to never checking their nevi. Comparison between sub-populations Respondents who consider that they are or are not exposed to the sun More respondents who considered themselves to be exposed to the sun (compared with those who declared that they do not expose themselves to the sun) declared that melanoma can develop anywhere on the skin surface (55% vs. 45%, P < 0.05), that melanoma risk factors are the presence of atypical nevi (80% vs. 74%, P < 0.05), or a personal (7 vs. 6, P < 0.05) or family (67% vs. 60%, P < 0.05) history of melanoma. They declared that the best measures for sun-protection are protective clothing (76% vs. 60%, P < 0.05), sun-glasses (24% vs. 15%, P < 0.05) and avoiding exposure to the sun at mid-day, between 12 pm and 4 pm (85% vs. 80%, P < 0.05). They reported being more frequently informed about skin cancers by the media (80% vs. 67%, P < 0.05) and having a positive image of a suntan (65% vs. 57%, P < 0.05). Using sun protection or not when exposed to the sun Respondents who declared they systematically protect their skin when exposed to the sun (vs. respondents who remain without protection during exposure to the sun) were more likely to know the definition of a melanoma (7 vs. 65%, P < 0.05), to know that melanoma can appear anywhere on the surface of the skin (59% vs. 48%, P < 0.01), and seemed to have a better understanding of melanoma risk factors: prolonged exposure to the sun (94% vs. 89%, P < 0.01), sunburn during childhood (77% vs. 68%, P < 0.01) and previous personal (75% vs. 69; P < 0.05) or family (69% and 6; P < 0.05) history of melanoma. They also had a better understanding of the fact that exposure to the sun promotes ageing of the skin (95% vs. 89%, P < 0.01) and the development of allergies (8 vs. 65%, P < 0.01). Respondents with at least one melanoma risk factor (vs. individuals with no risk factors) Respondents with at least one melanoma risk factor were more likely to know that melanoma can appear anywhere on the surface of the skin (58% vs. 5; P < 0.05), that prolonged exposure to the sun (95% vs. 92%, P < 0.05), and a personal (77% vs. 68%, P < 0.01) or family (7 vs. 6, P < 0.01) history of melanoma increases the risk of developing a melanoma. Their replies also showed that they do not believe self-tanning products to be a good form of protection against the sun (65% vs. 55%; P < 0.01). Fair-skin phototypes (I-II vs. III-IV) Respondents with fair-skin (phototype I and II) were more likely to know that a personal (80% vs. 69%, P < 0.01) and family (7 vs. 64%, P < 0.05) history of melanoma are risk factors for melanoma and that selftanning products do not provide good protection against the effects of the sun (70% vs. 56%, P < 0.01). Discussion This study provides insight into the knowledge of and attitudes towards sun-exposure of the French population through a nationwide telephone survey conducted at the end of summer Respondents frequently had a good understanding of the effects of sun and reported using effective sun-protection measures. This is possibly due to the frequent mass media sun-prevention and melanoma-prevention information campaigns that have been carried out in France over the past 10 years. A number of these have been sponsored by the French National Institute for Cancer 5 or by the French Union of Dermatologists (Syndicat national des dermatologues-venereologues) Melanoma day. Edifice Melanoma is the first nationwide study performed in France. We have no information on the extent of awareness of the French population as to the dangers of exposure to the sun prior to those campaigns and consequently cannot measure the impact. Our relatively encouraging findings should nevertheless be interpreted with caution, as only 7% of the individuals contacted accepted to take part in the telephone interview. Respondents are therefore likely to represent a population subset with a strong awareness of sun-related risks, which may differ from that of the general population. In addition, our study only investigated

5 Knowledge and attitudes on melanoma prevention and diagnosis 15 declared measures of photoprotection and not their actual use in real life. Even in this relatively well-informed population of respondents, a number of misconceptions still persist, such as the high rate of respondents declaring that it is useful to prepare the skin for sun-exposure, and the low rate of self-examination. Improved information messages in the future may help to reduce the ever-increasing incidence of melanoma in France. Acknowledgements Medical writing assistance was provided by Potentiel d Action and funded by Roche. References 1 INCa. La situation du cancer en France en Collection: etat des lieux & des connaissances [WWW document] URL fr/publications/69-epidemiologie/629-la-situation-du-cancer-en-france-en (last accessed 15 September 2014). 2 Eggermont AM, Spatz A, Robert C. Cutaneous melanoma. Lancet 2014; 383: Deville J. A theory of the quota surveys. Survey Methodol 1991; 17: Touboul C. Methodology of the EDIFICE Melanoma survey. JEADV 2015; 29(Suppl 2): S2 S5. 5 INCa. Exposition aux rayonnements UV: Institut national du cancer. URL (last accessed 17 November 2014).